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colorectal surgeon

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Question regarding how to code 25 and 57 modifiers

I admitted a medicare patient (day 1) with rectal prolapse. scheduled for flexible sigmoidoscopy.

Day 2 patient undergoes flex sig and I decide to repair the rectal prolapse on day 3.

Which days get the 25 and 57 modifiers?

I think day 1 gets billed as admission only.

day 2 gets billed as E & M with 25 modifier for the flex sig.

If I make the decision for surgery on day 2 do I bill both the 25 and 57 modifiers then?

If I don't add the 57 on day 2 does that E & M get denied?

Thanks
 
colorectal surgeon said:
Question regarding how to code 25 and 57 modifiers

I admitted a medicare patient (day 1) with rectal prolapse. scheduled for flexible sigmoidoscopy.

Day 2 patient undergoes flex sig and I decide to repair the rectal prolapse on day 3.

Which days get the 25 and 57 modifiers?

I think day 1 gets billed as admission only.

day 2 gets billed as E & M with 25 modifier for the flex sig.

If I make the decision for surgery on day 2 do I bill both the 25 and 57 modifiers then?

If I don't add the 57 on day 2 does that E & M get denied?

Thanks
Click to expand...

You would need both modifiers on the E/M - you also want to make sure your primary Dx is rectal prolapse, since that's the condition that prompted the service. Your E/M will probably deny without both modifiers. (To be clear: you can only get reimbursed for the E/M if it's unrelated to the procedure you're performing that day. If it had just been a pre-op clearance, you couldn't have reported it. It's only billable because you evaluated a new/distinct problem.) You may also consider adding a 58 modifier to your procedures, since they are related to one another. Hope that helps! ;)
 
Actually I was thinking about coding the flex sig as v72.83 other specified preoperative exam?

So even though I admitted this patient for the prolapse, I can't get paid for the E & M unless it's unrelated to the sigmoidoscopy?

I thought CMS had said you didn't need two different icd 9 codes when a 25 modifier is used? I do try and use two different codes when possible as it seems to make for a cleaner claim?
 
colorectal surgeon said:
Actually I was thinking about coding the flex sig as v72.83 other specified preoperative exam?

So even though I admitted this patient for the prolapse, I can't get paid for the E & M unless it's unrelated to the sigmoidoscopy?

I thought CMS had said you didn't need two different icd 9 codes when a 25 modifier is used? I do try and use two different codes when possible as it seems to make for a cleaner claim?
Click to expand...

You don't have to have a different diagnosis, but you do have a to have a significant, separately identifiable E/M, and it can't be part of the global surgical package (which a pre-op clearance is) Taking a look at what you did:

I admitted a medicare patient (day 1) with rectal prolapse. scheduled for flexible sigmoidoscopy. This is you decision for surgery for the flex sig.

Day 2 patient undergoes flex sig and I decide to repair the rectal prolapse on day 3. Here, you made a decision to repair the rectal prolapse, so any E/M that you did that day would have to be related to that decison for surgery, otherwise, it's not significant/separately identifiable from the flex sig pre-op and post-op services.

The only way you can have a separate E/M that's for the same condition as a surgery on the same day as the surgery, is if the condition whcih prompted the surgery has a sudden, acute exacerbation - the patient's overall condition has to change (and require re-evaluation). Does that make a little more sense? :eek:
 
Thanks. That does make a little more sense. What confused me is that the flex sig (45330) has a global of 0 days so I didn't think to put the 25 modifier on the initial visit where the decision for 45330 was made.
 
colorectal surgeon said:
Thanks. That does make a little more sense. What confused me is that the flex sig (45330) has a global of 0 days so I didn't think to put the 25 modifier on the initial visit where the decision for 45330 was made.
Click to expand...

According to CPT guidelines, the surgical package includes "Subsequent to the decision for surgery, one related E/M encounter the on the date immediately prior to or on the date of the procedure." That applies to everything in the surgery section of the CPT codes, whether there's a post-op global period or not. In order to distinguish between the E/M that's included with the flex sig, and a distinct E/M relating to the second procedure, you have to have the 25 modifier on the E/M.
 
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