# Modifier 57 - the e/m code



## JISF (Aug 20, 2012)

Can someone please give me some guidance for billing modifier 57. 
Our doctors routinely do hospital consults that result in surgery same day or the next day they also see patients in office and have the same situation. We bill the e/m code with a modifier 57 adn the e/m code still gets denied stating it is part of the surgery. 
It is all insurances including medicare that we are having this issue with. 

While all descriptions of modifier 57 say that we can bill this as long as it is a major surgery.


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## OCD_coder (Aug 20, 2012)

Mod-57 is appropriate to append to an E/M service whenever a major surgery has been decided.  A major surgery is defined as having a global period of 90 days.  Medicare's global period starts the day before the actual surgery, so you are only allowed 1 E/M either the day before or the day of, you won't get credit for 2 E/M's so close to the date of surgery.

Per the global surgical package you're only allowed 1 E/M service prior to the surgery and it does not matter if it is the same day, previous day or several days/weeks between the actual surgery (CPT ASST May 2009).  This is where many get confused and could be an issue.  There isn't enough information about your cases to really work the problem.


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## Naveen Rachagolla (Aug 20, 2012)

*Modifier 57*

I agree with the above statement, 

Mod 57 is for Decision for surgery, Mod 57 can be appended to only major surgeries of 90 day global period, it can be before the day of the surgery or on the day of surgery and it is appended to EM service and separately payable, and Mod 57 cannot be appended to minor surgeries of 0 to 10 day global period, because payment for Mod 57 is already included in global surgical pacakage and moreover the count for minor surgeries starts from the day of surgery and plus 10 das following surgery.


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## JISF (Aug 21, 2012)

Ok let me clarify a little more . Our Dr. is on call sees patient as a consult( initial hospital visit) in hospital and decides that the patient needs surgery, depending on the surgery he either does it later that day or the next day. we bill the e/m visit  with a 57 modifier  an then bill the surgery as it should be coded. we are getting denied on all of the e/m visits saying they are included in the surgery. If it helps we are orthopedics so we are talking about fractures and such that all have 90 day global periods. 
The way I read the rule is that those e/m visits should be covered if we bill the 57 with them .


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## jbrightw (Aug 22, 2012)

E/M visit with 57 modifier are not included in the surgical package. I think you can appeal for that.

Please refer CPT Assistant, May 2003, Volume 05, Issue 13, pages 17-18 

'When a physician provides an E/M service that results in the initial decision to perform a surgical procedure, it would be appropriate to append modifier '-57,' Decision for surgery, to the E/M service code to distinguish this as a separate service from the global surgical package, as defined by CPT surgery guidelines.'

Brightwin


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