Cardiology Coding Alert

Question: The definition of modifier 57 is "decision for surgery," so why do I get notices this modifier is wrong when I append it to an E/M that leads to a cardiac cath?

New Mexico Subscriber

Answer: The answer has to do with global days. For those payers following Medicare rules, you should append modifier 57 (Decision for surgery) to an E/M code when you report the E/M on the same date as a major surgical procedure or on the day before. A major surgical procedure is one with 90 global days. You can expect to find that cardiac caths have 0 global days. Always check before coding.

Dig deeper: Modifier 57 applies when the cardiologist performs the E/M to determine whether the major procedure is necessary for the patient and when the E/M is distinct from the usual pre-work performed for a procedure. Typical examples of major procedures cardiologists perform are pacemaker and ICD insertions.

Minor procedures: Services with 0 or 10 day global periods (minor procedures) include payment for the decision to perform surgery, so you should not report a separate E/M for that process. If the patient does have a separately reportable E/M on the date of the minor procedure, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service). You also may append 25 to a distinct E/M performed on the same date as an XXX global service.

Resource: Check out Medicare Claims Processing Manual, Chapter 12, Section 30.6.6, "Payment for Evaluation and Management Services Provided During Global Period of Surgery," and Section 40.2, "Billing Requirements for Global Surgeries," to see the wording straight from the source.