"An in-patient consultation was done and later on the same day an in-patient surgical procedure was performed. Medicare has paid for the consultation code but has denied payment for the procedure stating that “a CPT or a CPT/modifier combo is not compatible with another procedure or CPT/modifier combo provided on the same day according to the CCI.” The codes used were CPT 99222 and CPT 28820 (T6). Any suggestions?”
I actually have a few suggestions. Unlike the E/M changes that went into effect on January 1, 2021 for patients seen in the office or outpatient setting, for patients that are seen in the hospital impatient setting, the 1995 or 1997 E/M Guidelines are still in effect. The definition of E/M code 99222 is the following: Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components;
-A comprehensive history
-A comprehensive examination, and
-Medical decision making of moderate complexity
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit.
This leads to the first suggestion. Since this E/M service is based upon the 1995/1997 Guidelines, in reality, based upon a podiatrist’s limited scope license, a podiatrist cannot bill E/M code 99222 based upon the performance and documentation of a Comprehensive Examination. A Comprehensive Examination is an examination that includes the performance and documentation of ALL designated ELEMENTS in at least 9 Organ Systems or Body Areas OR an exam that includes the performance and documentation of at least 2 ELEMENTS in ALL the Organ Systems and Body Areas.
Based upon the podiatrist’s limited scope license, a podiatrist is only licensed to EXAMINE and TREAT 5 organ systems. They are Constitutional, Cardiovascular, Musculoskeletal, Skin/Dermatologic and Neurologic. Of course, only those aspects of each of these organ systems that a podiatrist is licensed to examine and treat apply. The bottom line is that in the hospital inpatient setting, a podiatrist can only bill E/M code 99221 for the Initial Hospital care of a New or Established Patient for the first hospital inpatient encounter.
With respect to CPT code 28820 which is defined as: Amputation, toe; metatarsophalangeal joint, this is classified as a major surgical procedure code with a 90 day postoperative global period. In order to be reimbursed for both the E/M service and the procedure, the E/M service needs to be appended by the appropriate modifier. The modifier in question is 57. The 57 modifier is defined as: Decision for Surgery. Modifier 57 is used to identify an E/M service, provided on the day before or day of surgery, in which the initial decision is made to perform major surgery (90 day follow-up). The “Global Surgery Policy” includes the E/M service provided on the day before or the day of the major surgical procedure unless the E/M service resulted in the decision to perform surgery. You may use -57 modifier with E/M codes 99202-99499. Therefore, I believe that if the E/M service would have been appended with the 57 modifier, both the E/M service (CPT 99222) and procedure (CPT 28820) would have been reimbursed.
This is my opinion.
Michael G. Warshaw
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