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Otolaryngology Coding Alert

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E/M-57 Denials

Question: My otolaryngologist submits an inpatient hospital visit code (such as 99223 or 99254) with modifier 57 appended, in addition to surgery code(s). Medicare denies these codes stating the allowance is included in another procedure, and pre-op care is included in the allowance of the surgery. What are we doing wrong?

Tennessee Subscriber

Answer: The problem could be your modifier. Make sure the otolaryngologist is using modifier 57 (Decision for surgery) on claims involving a major surgery, a code that has a 90-day global period as indicated in the 2007 Medicare Physician Fee Schedule. If the surgery is really a minor procedure, a code that contains zero or 10 global days, modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) instead applies.

With 25, the E/M must be significant and separate from the minor preoperative evaluation that the surgery includes. Although CPT does not require different diagnoses with a modifier 25-E/M, the insurer may require a separate diagnosis to cover the -unrelated- same-day E/M.

Modifier 57 indicates that although the hospital visit is usually part of the surgery's 90-day global period, the physician made the decision for the surgery during that encounter, making the E/M service separately reportable.

Example: The otolaryngologist admits a patient with parotitis to the hospital. Three days later, the patient develops a parotid abscess that requires draining. After examining the patient on rounds, the otolaryngologist makes a decision for surgery (to drain the abscess in the operating room). She indicates that at the hospital visit she made the decision for surgery by appending modifier 57 to 99231-99233 (Subsequent hospital care, per day, for the E/M of a patient), which she reports in addition to the major surgery (42305, Drainage of abscess; parotid, complicated).

But if the surgeon drained the abscess at the patient's bedside, she would instead use 42300 (- parotid, simple), which has a 10-day global period. If the physician performed and documented the hospital care as significant and separate from the drainage, she could append modifier 25 to 9923x. Without a separate diagnosis, the payer may include the E/M in 42300's allowance.

Alert: If you are properly using modifier 57 on a major surgery and the carrier still denies the E/M, you should appeal. The denial could be a bug in the Medicare carrier's system. Some practices have noted this problem, so make sure it's not the payer that's making the mistake.