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Feb 9th, 2016 - cmc2012 14 

Question on CPT® code 99219

Hello there,

Patient is seen in the surgeon's office one or two days before major surgery - Is it okay to bill 99219 with modifier 57 on the same day of the major surgery?

I am so confused about the use of 99219. Our surgeon bills for it on the day of major surgery even when he's seen the patient one or two days before the surgery....

Please help!

Thanks!

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Feb 9th, 2016 - codinqueen 57 

re: Question on CPT® code 99219

I don't code for surgeons, since I code for facilities only, but per CPT® book you can't bill 99219 AND a surgical procedure on the same DOS by the same DR or member of his group. 99219 would be used if the pt was admitted to observation status, but only if your Dr didn't do any surgery on him-in other words if MD was directing care and doing exams, etc, but NOT the surgeon. The global service would encompass the observation E & M performed by the surgeon and I believe it to be considered fraudulent to bill both codes for the same DOS by the same Dr. And depending on the pts' surgical procedure there would be a global period that would preclude billing any E&M for the surgical global period following the procedure. See CPT® book instructions re Initial Observation Care, especially the paragraph directly above 99218.

Are payors actually PAYING both of these codes for the same DOS? If Medicare/Medicaid is involved, I would immediately rectify this situation or get a new job PDQ. The United States Office of the Inspector General can and will go after funds paid by Federal entities by mistake and those generated by coding errors can cause lots of headaches, including jail time for fraud. And they WILL investigate other patients' bills by the same surgeons' practice, looking for more errors & they will demand repayment as well as fines & penalties on a percentage basis of what errors they find when they review other charges and codes. This is a Pandora's Box.. I am glad I don't work there!

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Feb 10th, 2016 - Codapedia Editor 1,399 

re: Question on CPT® code 99219

You may certainly bill an OBS admission on the day of a major procedure IF and ONLY IF the visit was the one at which the decision for surgery was made. Then, append modifier 57.

Payment for a major surgical procedure includes the E/M service the day of and the day before the major procedure, unless it is the visit at which the decision for surgery was made.

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Feb 10th, 2016 - codinqueen 57 

re: Question on CPT® code 99219

Oh, yes, that is true if the decision to perform surgery was made that same day. This is common with pts who go to the ER with a fracture, and the ortho surgeon is called in, & he then decides to do surgery that day and admit after examining the pt. However, the surgeon can't charge an OBS E/M on the day of surgery unless the decision for surgery is made that same day or unless there is another dx he is also following that is not related to the surgical procedure. Fractures are usually 90 day global periods. I am sorry if I misled anybody. The modifier is most definitely necessary in those cases. Per the original poster's message, it looks like this DR ALWAYS bills like this, even if he knows he will do surgery the day before and she didn't mention any modifiers or extenuating circumstances.

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Feb 11th, 2016 - LBAROGIANIS 250 

re: Question on CPT® code 99219

If the patient is seen in the Surgeon's office 1 or 2 days previous, you would not bill an observation code. This is for hospital use only. You will need to bill an office visit. Also, on global periods you can't bill the day of or the day after on a surgery.

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Feb 11th, 2016 - codinqueen 57 

re: Question on CPT® code 99219

I believe MD can bill an IP or OP consultation or ER or office visit on the day of surgery with an E/M code IF the decision for surgery is made on that same day, where he examines the pt in the office or hospital and decides surgery is necessary that same day. If the pt has, say, a head injury & femur fx from a fall and comes to ER and needs to be observed for the head injury as well as have a femur fracture fixed, there would probably be another Dr who would bill for the Observation or IP or OP E/M for the head injury and the ortho surgeon could bill for the surgery with a surgery CPT® code and also an E&M code for the consultation/ER visit where he examined and decided need for surgery with a -57 modifier if all points of E&M code are covered in order to bill for the consult or ER/office visit E&M. It has been over 20 years ago that I worked for ortho MDs, so I am a little rusty on this point, but if the surgeon thoroughly examines the pt and decides surgery is necessary on the same day, it can be billed for the E/M code with -57 modifier, or at least it could be over 20 yrs ago. Things may have changed over those 20 yrs. Usually the pt was examined on an ER visit, or consultation in hospital or office, by the ortho MD and admitted for surgery on the same day. We billed the IP or OP or office visit or consultation/ER visit AND the fracture care CPT® codes then & as long as it was billed with mod -57 it was paid in most cases. Sometimes we had to appeal with certain HMOs- I won't name them here- to get both codes paid, but we usually won. However it is important to realize that ALL the component criteria of the E/M code must be met to do this. The documentation by the DR has to be there to prove your case to get paid for the E/M code in addition to the surgical CPT® code, and modifier 57 has to be reported. Remember if MD didn't document it, he didn't DO IT because it can't be proven.

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