I bill for a surgeon who sees patients at 2 different hospitals. I seem to be coming across a problem getting paid for emergency surgeries at one of these facilities. For example;

Patient goes to emergency room with RUQ pain and vomitting, etc. Surgeon is consulted, he performs h&p and decides to take patient to surgery for Laparoscopic Cholecystectomy. Patient is discharged the next day.

I bill this scenario fairly frequently for both hospitals with an outpatient e/m code (99203/4), modifier -57 for decision for surgery, and the surgery code (47562); all with place of service of 22 (outpatient). There is no pre-authorization to report since it is an emergency surgery.

I get paid without any problems for one hospital, but the other seems to always cause problems. The payer comes back saying pre-auth absent. When I call the hospital billing department, they tell me everything is in order, they were paid, and if a pre-auth was needed, it was in place. When I call the payer, they say "if the surgery was outpatient, it needs a pre-auth. If it was emergency it does not." but they don’t offer any additional information on where the hang-up is.

So my question is, what are the triggers in the hospital billing process to show that a surgery was an emergency and a pre-authorization should not be necessary for the performing surgeon? OR, am I billing this scenario properly? Sometimes, I do bill the h&p with the ER e/m code and pos (23), but the surgery is always with an outpatient pos.

What am I missing here? Any insight appreciated.

Thanks, Nancy