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Observation and surgery same day

Sally Posted Sat 18th of February, 2017 12:47:57 PM
I have a couple cases where the doctor admitted patients to observation(both thought they were admitting to in patient but the hospital changed it to Observation) and then took them to surgery the same day. Is it appropriate to charge 99218 with a 57 modifier? Since the patient will be in a 90 global after the surgery I assume there will be no discharge from observation charge. Please advise on this.
SuperCoder Answered Mon 20th of February, 2017 02:13:47 AM

Greetings from!


If an E/M service provided the day before or the day of a major surgical procedure for the purpose of deciding whether to perform this surgical procedure or not, the E&M service is separately reportable with modifier 57.


Other preoperative E&M services on the same date of a major surgical procedure (e.g. clearance for surgery) are included in the global payment for the major surgical procedure and are not separately reportable.


Please feel free to write if you have any concern or questions.



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