EM Coding Alert

Knowing why a claim with modifier 57 is denied, may help your appeal. 

Modifier 57 is under heavy scrutiny from payers, including Medicare. If you aren’t using this modifier correctly, your practice may face denials or owe money back to your payers at audit time.

Review two common culprits behind modifier 57 (Decision for surgery) denials and learn what you can do to avoid them.   

Know Your Payer’s Definition of a Global Period 

Because some payers have a different definition of a global period than CMS, they may deny a claim with modifier 57. Typically, these payers don’t think the E/M service should be billed separately.

CMS defines a global surgical package as “…all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the pre-operative, intra-operative and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”

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 surgery 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, for their procedures with a 90-day global, the day of or day before surgery. But many other payers, including many of the Medicaid programs, don’t include a day before surgery so the only thing they’re concerned about is E/M on the same day as the surgery,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, audit manager at CHAN Healthcare in Vancouver, Wash.

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

When in doubt, experts suggest following the CPT^®/CMS rules. “I do know that the different payers have different ideas about global days,” says Suzan Berman (Hauptman), MPM, CPC, DEDC, CEMC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn. “I tend to be conservative and use the modifier as it has been directed by CPT^®/CMS as the day before surgery or the day of surgery when the decision was made at that visit.”

Good practice: AMA suggests keeping a health insurer reference log where you can include the payer’s global period definition, so that it’s at your fingertips when you are coding.

Be Aware of Possible Problems with Payer’s Claims-Editing Software   

When you have a continually denied claim for an E/M service and surgery, when the decision for surgery was made as a result of the E/M service, the reason for the denial may be because your codes were mistakenly bundled. The bundling may happen due to the payer’s claims-editing software not recognizing modifier 57.

What to do: Talk to the payer to determine if the denial is the result of a software limitation or the denial is based on a billing rule. Bucknam recommends doing three things when a payer continually denies your claims:

• Talk to your payer representative to find out what you can do to get your claim approved. If they say their policy is to not pay for an E/M service on the day of a procedure, then take note of that and don’t waste your time on what will never be paid.
• If you learn that the payer will only pay the E/M with a modifier 57 on appeal, ask them if you can group your E/Ms together and submit them once per month. “If they approve, you can save time and money by not appealing on a case by case basis,” Bucknam adds.
• If your reality is that you aren’t going to get an E/M and a procedure paid on the same date, make sure you review your reimbursement. Some high level E/M services pay more than some minor procedures. “If you’re only going to get paid for one of them, make sure it’s the one that pays the most,” she says.