Modifier 57; Billing for Telephone Services; Retroactive Reimbursements

Modifier 57

Q: If we see a patient in the office for profuse vaginal bleeding and we send her to the hospital for surgery that day, would modifier 57 be appropriate for the E&M visit?

A: Maybe. When you send her to the hospital, is the provider who is doing the surgery part of your group? If so, the provider is pretty much interchangeable with the provider who saw the patient in the office. In that case, either modifier 25 or 57 is appropriate.

The next question pertains to the surgical service. Did the surgical CPT code have a 90-day global surgical period or a zero- to 10-day surgical period? If the former, modifier 57 is correct. If the latter, use modifier 25 on the office visit.

Serving as Attending and Performing Surgery

Q: As a surgeon, can I bill for an H&P plus discharge summary when I perform the surgery and I am the attending?

A: This question doesn't really have enough information for me to provide an accurate answer. To bill the H&P, you need to be the admitting physician of record. If the patient is admitted the same day he has the surgery, and it is a major surgery with a 90-day global period, the admit is considered part of the E&M visit which is bundled into the pre-op component of the surgical code.

Of course if you make the decision to perform the surgery that day (see the previous question where you would use a 57 modifier) this unbundles the visit from the surgery.

If you admit the patient, perform the surgery, and discharge him the same day, you need to use the same-day admit/discharge codes 99234 to 99236. But again, the same-day part is more about the global period and the surgical code you are billing.

If the discharge is being done the day after the surgery, or a few days after, and the patient only received the typical post-op care for that surgery, then the discharge day is part of the global package and would not be expected to be billed separately.

The rules are pretty clearly spelled out in the subsection guidance for the E&M codes and the surgical package language in the CPT Manual.

E-Codes

Q: I know of the E-code E928.9 (unspecified accident), but is there a code for no accident, no known injury? I see a lot of kids with pain who did not have an accident and they have no specific injury, but they need an X-ray. The E928.9 indicates there was an accident, it just wasn't documented.

A: If there was no injury or accident, you don't need an E-code! That's what E-codes are for. Just go with the sign or symptom. There is nothing wrong with a diagnosis code of "XXX" pain.

Billing for Telephone Services

Q: When reviewing laboratory results with a patient over the telephone, can we submit this as a 99211 Level 1?

A: Definitely not. There are codes for telephone services, but even these state the subject of the conversation needs to be separate from previous visits and unrelated to the next visit.

99211s are for professional services provided by or through office staff: weight checks, blood pressure checks, maybe uncomplicated suture removals.

For example, if a patient complaining of a UTI is seen by a nurse and undergoes a urinalysis, a physician may write the patient a prescription.

But it's often overlooked that the physician involvement needs to be clear. At the very minimum, a signature from the provider needs to be in the chart relating to the 99211 or incident-to service provided. A better convention would be an actual note indicating the provider's specific knowledge of the service: "UA reviewed, will Rx ABC …," or "BP stable cont. XYZ …," etc. Some groups have developed templates for this - just like other E&M templates - organized along the lines of the complaint or service. The ancillary or performing staff fills out much of the template and it's then signed by the physician. That may be the best course.

Your question does scare me a bit. Medicare's requirements are somewhat different. Although the physician does not need to be in the room for each 99211 service provided for a Medicare patient, the physician must initiate the service as part of a continuing plan of care in which he will participate. And always, the physician must be in the office suite when each service is provided. This means that the patient must be in the physician's office. Otherwise, Medicare does not consider that the "encounter" occurred.

Retroactive Reimbursements

Q: You wrote an excellent prior article regarding physicians' undercoding tendencies. I was wondering if you can shed any light on the process of getting retroactively reimbursed if it has been found that the undercoding has consistently been ongoing for a couple of years. Is there any way to resubmit those claims?

A: Nice idea - but I can't really see any of the payers going for it! After all, you filed the earlier claims, and they likely paid them.

Medicare is obligated to pay claims at the correct (supported by documentation) level when it is reviewing claims prospectively. I'm not certain that it is under that obligation when reviewing retrospectively (after the claim has been paid).

So you can try it certainly, but I suspect that this will not result in a windfall. But call the various payers and ask them - it never hurts to ask.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the November 2011 issue of Physicians Practice.