Wiki Pre-op billing more than 2 days prior to surgery

[dcheverie]

is it acceptable to bill for a pre op visit more than 2 days before the actual surgery as long as the physician documents, the H&P, the complex decison making, etc..and other criteria to support the level E/M he is billing?

 

[tmerickson]

If you mean billing an E/M code...then I assume you are billing a "decision for surgery" office visit. You would use modifier 57. BUt you can only do this if this is the first visit theyprovider is seeing this pt for the problem/decision for surgery. If he/she saw pt last week and they decided to do surgery, then the pt is seen again this week, the 2nd encounter is included in the global code and not billed seperatly

 

[kerri0402]

Pre op billing more than 2 days before surgery

We have had discussion in our office about this before. I was under the impression for the pre op, you can bill an E and M with the 57 modifier like you stated. Someone else is insisting the 57 can only be used if the surgery is done within 24-48 hours. I don't see where in the description of the 57 modifier it limits or states a time period? If they are seen 14 days before for a pre op, you can still use the 57, am I correct? Thanks!

 

[OCD_coder]

Only the initial consultation where the decision for surgery was initiated by the surgeon-provider is billable. Pre-op evaluations by the surgeon are included in the surgical CPT code and are not billable no matter when they are performed. Adding a modifier 57 is permitted whenever the decision for surgery is made, you should not get a denial for it. It's used for tracking and data mining internally when necessary; the 24-48 is an internal rule some companies have initiated. Here is the CPT Assistant rules that make it clear.

PREOP VISITS – Guidelines **
Source: CPT Assistant MAY 2009 (AMA and CMS)

If the decision for surgery occurs the day of or day before the major procedure and includes preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H and P) alone).

If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H and P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package.