Emergency procedure

A physician was doing a ward round in the hospital and was called to attend to an emergency patient. The physician later realised after treating the patient, that he is not a participating provider with the patient insurance. My question is :
1. What will be the appropriate modifier to use to bill this patient insurance that will make them to pay.
The procedure is:

Preopereative Dx: pituitary adenoma
Postoperative Dx: pituitary adenoma
Procedure: Transsphenoidal approach for excision of pituitary adenoma.
Surgeon and cosurgeon performed this procedure

I code it as this:
ICD Code: 227.3
CPT® Code: 62165-62

Kindly assist .
Thanks.

Oct 23rd, 2012 - agent00711 151

re: Emergency procedure

Modifier -62 is not appropriate to be used in the instance in which you have explained. You need to know the medical payment policy for the carrier when services are rendered in the ER for a non par provider. The patient may have out of network benefits if not, since you are not par, you should bill the patient appending a modifier is not your answer.

Oct 23rd, 2012 - kehinde 3

re: Emergency procedure

Yes, i agree that i have to check the patient insurance's benefit, but when you have the surgeon and a cosurgeon performed a surgery, you still need to append modifier 62.

Thanks

Oct 24th, 2012 - agent00711 151

re: Emergency procedure

My apologizes, do I misunderstand. The scenario you described was rounds not surgery. In the instance of rendering a ER consult while on rounds modifier -62 would not be appropiate. In addition, appending any modifier on a service when the provider is not par, will not necessarily constitute payment of your claim. How the payor processes the claim will be contingent upon the subscibers policy and since your provider is non par in the event there are no provisions in the policy for reimbursement of out of network providers, you can freely bill the patient. Be sure you POS code reflects ER and that will alert the carrier to apply applicable emergency room benefits. Best wishes!

Oct 24th, 2012 - kehinde 3

re: Emergency procedure

I am so sorry to put it there that the physician performed a surgery. Thank you so much for your help!!
But in this case, do i also code the E/M too before coding the surgery ?

Oct 24th, 2012 - agent00711 151

re: Emergency procedure

I would code the appropiate E/M in addition to the surgery and append modifier -57 (Decision for surgery).

Oct 24th, 2012 - kehinde 3

re: Emergency procedure

Thank you so much!!

Oct 24th, 2012 - agent00711 151

re: Emergency procedure

You are most welcome!