Revenue Cycle Insider

The key for ED providers is to count the global days.

When your emergency department (ED) providers perform procedures along with evaluation and management (E/M) visits, the best way to collect for both services is to use a modifier. But knowing which one to use can be challenging.

You’ll usually append one of these two modifiers to your E/M code:

• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)
• Modifier 57 (Decision for surgery)

Read on to discover the differences between the modifiers, how to choose, and when you can qualify a procedure as a “surgery.”

First, Differentiate 25 From 57

Although you may not perform a many actual surgeries in the ED, it’s possible that your providers handle services that are classified as surgeries, and these may warrant the use of modifier 57 with your ED E/M code (99281-99285 [Emergency department visit for the evaluation and management of a patient …]).

Here’s the difference: You should use modifier 57 for procedures with a 90-day global period, whether or not you would classify those as surgeries. For instance, many fracture care codes fall into this category. In contrast, you’ll use modifier 25 with procedures that have a 0-dayor 10-day global period. These types of procedures are what Medicare defines as minor.

Do this for 57: Use modifier 57 if the claim meets all of the following criteria:

• The E/M occurs on the same day of or the day before the procedure
• The E/M service directly prompted the provider’s decision to perform surgery
• The surgical procedure following the E/M has a 90-day (major surgery) global period
• The same provider (or another provider with the same tax ID) provided the E/M service and the procedure

Because modifier 57 claims involve an E/M service that results in a decision for surgery, you would generally expect to see the same diagnosis code for both the E/M and the surgical procedure. It would be unlikely the physician would make a decision for surgery based on a significant problem that was unrelated to the procedure.

Example: A 36-year-old patient slips in a parking lot, landing awkwardly on their left lower leg. The ED provider diagnoses him with a tibial shaft fracture, reduces the fracture, and applies a cast. Because the E/M service prompted the decision for the surgical procedure, append modifier 57 to the E/M code, along with 27752 (Closed treatment of tibial shaft fracture (with or without fibular fracture; with manipulation, with or without skeletal traction)).

Do this for 25: Your modifier 25 claims should meet all of the following criteria:

• The E/M occurs on the same day as the procedure
• The procedure following the E/M is minor (has a 0-day or 10-day global period)
• The E/M service is both significant and separately identifiable from any inherent E/M component that the procedure involves
• The same physician (or one with the same tax ID) provides the E/M service and the subsequent procedure

Example: A patient complains of pain in their foot ever since walking barefoot on a boardwalk. The physician examines their foot and finds a splinter in the subcutaneous tissue. You’ll report the splinter removal with 28190 (Removal of foreign body, foot; subcutaneous), which carries 10 global days. Append modifier 25 to the appropriate-level ED E/M code.

Know Your Payer’s Definition of a Global Period

Not every payer defines a global period the same way, but many insurers follow the lead of the Centers for Medicare & Medicaid Services (CMS). CMS defines a global surgical package as “all necessary services normally furnished by a provider (or members of the same group with the same specialty) before, during, and after a procedure.” CMS, along with most other payers, assigns a procedure or service to one of the following types of global surgical packages:

• 0-day: Only the day of the procedure is a part of the package
• 10-day: The day of surgery and 10 days following the surgery, totaling an 11-day package
• 90-day: One day before the surgery, the day of the surgery and 90 days following the surgery, totaling a 92-day package

Both Medicare and CPT^® include the day of, or day before surgery as part of their procedures with a 90-day global period. But several other payers, including many of the Medicaid programs, don’t include a day before surgery in the surgical package, so the only thing they’re concerned about is E/M on the same day as the surgery.

What to do: Once you sign a contract with a payer, you’re obligated to know its rules, including its definition of a global period. If you don’t follow the payer’s billing guidelines, you’re most likely losing money by not billing for payable services or spending additional funds on appeals.

Good practice: Keep a reference log where you can include each payer’s global period definition, so that it’s at your fingertips when you are coding.

Document ‘Separately Identifiable’ Nature of 25-Modified Service

Payers across the board will only allow modifier 25 for clearly “significant and separately identifiable” E/M services. Why? Because even minor procedures include a small E/M service within the value of the procedure. Therefore, in order to be paid for both the E/M and the minor procedure, your documentation must demonstrate to the payer that the E/M was significant and separately identifiable from the minor procedure. 

Here’s how: Look at the documentation and disregard anything that is directly related to the procedure performed. Examine what’s left to determine if it is indeed significant, separately identifiable, and medically necessary. If so, you should be able to use modifier 25.

Reminder: You do not have to have different diagnoses to compliantly report modifier 25 with an E/M code. But if you do have a situation where you evaluated one diagnosis for the E/M and addressed another diagnosis with the procedure, you should link the different diagnoses to the corresponding CPT^® codes.

Torrey Kim, Contributing Writer, Raleigh, NC