ED Coding and Reimbursement Alert

Question: When should I use modifier -57 (Decision for surgery)? Does this modifier apply to patients admitted to the hospital who go directly to the operating room? Does it apply to patients who receive laceration repair or fracture care? Should I append this modifier to the E/M code?

Kansas Subscriber

Answer: You should append modifier -57 when the evaluation and management service the doctor performed resulted in the decision for surgery -- for example, an emergency department physician's examination of a patient that revealed a fractured tibia.

You should report the E/M code -- in this case, possibly 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history, a detailed examination, and medical decision making of moderate complexity) -- to describe the service that led to the decision for the surgical procedure. For the surgery, you'll report 27750 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; without manipulation).

For Medicare and payers that follow Medicare rules, you should only append modifier -57 to procedure codes that have 90-day postoperative periods. Generally, fracture care codes have 90-day global periods, while laceration repair codes have only 10-day global periods, so keep this in mind when deciding about modifier -57.

The "major/minor" concept applies to Medicare patients with modifier -57 appended to the E/M that led to a major procedure (0- to 90-day global period), and modifier -25 applied to the E/M that led to a minor procedure (0- to 10-day global period) if the physician performed a separately identifiable service. If the patient goes directly to the operating room for the surgery, you would only append modifier -57 to the code the operating physician reports. For the emergency physician, then, you would report an unmodified E/M code.