Wiki Inpatient Visits Leading up to 90 Day Global Surgery

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coffee2day

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Hello, any advise on how to bill this scenario for the e&m visits in the hospital?

The provider is billing e&m inpatient visits leading up to a 90 day global surgery, and I am unsure how to bill these inpatient visits. Our software edits telling us a modifier is needed for the day before visit and same day visit, see below -


initial visit 99221 06/05 decision for pacemaker insertion next day
subsequent visit 99232 - 06/06 hospital subsequent visit, labs done, procedure ended up being rescheduled to next day
subsequent visit 99232 06/07 pt has high wbc they did labs and chest xray to rule out pneumonia, then on this same day did the major surgery 90 day global of insertion of pacemaker.


Our software is editing for dos 06/06, 06/07, any advise on what modifier 57 should go? Should any of these be changed to a preop visit? I feel the MD is monitoring/treating the underlying condition at all visits. MOd 57 would go on 06/05 but this is two days away from the surgery so it doesn't need to I think. But the other two dates, should I just process as-is without modifier 57, and ask for appeal if denied (mod 57 doesn't apply to 06/06 or 06/07 since decision for surgery made on 06/05)?

Thank you,​
 
Because it is a major procedure the day before is included in the global period and the E&M on the same day is included as well. So I would put the -57 on the 6/6 service and then bill only for the surgery on 6/7.

You can bill nothing on 6/6 and bill both the E&M and the surgery on 6/7 (with a -57 modifier on the E&M) but I think it looks "cleaner" to bill the above scenario.
 
I don't think a modifier is needed on 6/5 since its not the day before the major procedure

6/6 E&M is global since its subsequent to the decision for surgery

Surgery billed on 6/7
 
Since a decision was made regarding the surgery on 6/6 (to wait another day) I would bill for it with the -57. YMMV
 
What if patient is seen in hospital on 7/23, decision made for surgery pending clearances(ER 99283), then patient is seen 3 more times inpatient (7/24, 7/25, 7/27) before surgery takes place on 7/29? Do I just bill 7/23 and surgery or can I bill any of the other subsequent visits? This is a medicare patient. Thanks for any input!
 
In all my years of billing, I interpret that when a physician decides that a patient needs surgery is not the same as the exam for the decision for surgery.

How? Well, a physician can decide that a patient needs surgery but that patient is going to need pre-operative clearance. Not until the day before (for major procedures) or day of (for minor procedures) does the Physician decide that the patient is healthy enough to undergo their procedures and that exam is the exam that I apply the -57 modifier to. The Physician has made his decision that the patient is healthy enough for surgery and the surgery will proceed.

So in your scenario, I would bill for all of those services since the exam that decided that the patient was healthy enough to undergo the surgery was made the day before (for a major procedure) or the day of (for a minor procedure).

This is how I have billed these scenarios for years and I have had no issues. YMMV
 
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