Wiki Modifier 57 - surgical package

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AR2728

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When an initial E&M or H&P results in decision for surgery we normally bill the E&M with a 57 and the surgery even though performed the same day. However, more and more insurance is denying the E&M as part of the surgical package. I completely understand a preop visit is included in the surgical package. However, without an initial evaluation the physician could not even determine what course may need to be taken. I just feel our physicians are being short changed. Is anyone else having similar issues? At this point, I don't know that it is even worth continuing to attempt to bill an initial exam when it results in surgery.
 
I have had similar issues, and have had all of them come back and pay after submitting an appeal with records. So it is probably worth your time to type up a letter and send in records, as long as they support the decision for surgery.
 
57 modifier

For my inpatient charges are the diagnosis codes for the consult with the E/M.

Then for the procedure I use the diagnosis code for the procedure if they do not match.

example -- my E/M diagnosis may be chest pain

My procedure diagnosis code is the LBBB.

I haven't notice any rejects yet
 
One thought

I do reviews and find that doctors admit patients electively for surgery, then do a H+P and try to bill it with a 57 modifier - they KNEW the member was having surgery when they admitted them.
 
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