Modifier 57 Is Not For Consults Only

By Author: Nancy Rose
Total Articles: 53
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Although Medicare does not accept consult codes, you can still opt for modifier 57.


Question: We used to apply modifier 57 to inpatient consult codes in our ob-gyn office. And since Medicare does not accept consult codes, how should we use this modifier?


Answer: The immediate answer is you should use modifier 57 (decision for surgery) to the non-consult inpatient E/M code that the documentation supports.


Say for instance the ob-gyn carried out a 2009 level-three inpatient consult in which the ob-gyn figured out the patient required an exploratory laparotomy later that same day owing to severe abdominal distention and pain as well as some uterine bleeding. Adding the modifier to the evaluation/management code will help show payers why you are going for an EM to add to the major surgery carried out later that day, 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]).


For the current year, the exact E&M code you select will ...
... depend on the circumstances specific to the visit; say for instance whether the visit is the first or second ob-gyn visit during the admission. However say for instance you are coding the ob-gyn's first visit to an inpatient. Your documentation may support 99221 (Initial hospital care, per day, for the E/M of a patient, which requires these three vital components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that's straightforward or of low complexity ), which has requirements like those of 99253 (Inpatient consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity).


You should go for modifier 57 to the evaluation and management code. However if the ob-gyn is the principal physician - the one overseeing the patient's care and the one who's admitting the patient - see to it that you append modifier AI (principal physician of record), also. This would be the case if the ob-gyn admitted the patient for the abdominal pain and bleeding but later on decided to go for her surgery that same day.