EM Coding Alert

Pay attention to the global period.

As a coder, you know how important modifiers are on your claims. Modifiers allow you to tell your payers that although a specific circumstance may have altered the service/procedure your physician performed, the definition or code of the service stayed the same.

Bust three common myths about modifier 57 (Decision for surgery), a modifier option for your evaluation and management (E/M) services, and pave your way to cleaner claims.

Myth 1: To use modifier 57, the procedure following the E/M service must be minor.

Truth: You should use modifier 57 only when the surgery is major, never minor.

“The 57 modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery,” according to the Medicare Claims Processing Manual 40.2.

Definition: Codes with a 90-day global period are considered major surgeries, according to the Medicare Physician Fee Schedule.

Don’t forget: “Remember that while we normally think of it [modifier 57] being usedprior to the original surgery, it also applies to any decision to do follow-up surgery during the 90-day global period of the original surgery unless that surgery was to be performed in stages,” says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

Myth 2: You can use modifier 25 and modifier 57 interchangeably.

Truth: You should never confuse modifier 57 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

As previously mentioned, you should append modifier 57 only when the surgery is major, which means it has a 90-day global surgery period.

“If the patient is having major surgery, which is a surgery that has a 90-day global surgical period, and the physician performs an E/M on the day before or day of the surgery, then use the 57 modifier,” says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

On the other hand, you should only append modifier 25 to indicate a distinct E/M with a minor procedure (zero or 10-day global period) performed on the same day.

Tip: Suzan Hauptman, CPC, CEMC, CEDC, AAPC Fellow, senior principal of Ace Med Group in Pittsburgh, Pennsylvania, gives a helpful way to remembering this code by knowing it is a larger number than the modifier 25, thus it is used for major procedures as opposed to minor ones.

“A/B MACs (B) may not pay for an evaluation and management service billed with the CPT^® modifier -57 if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period,” according to the Medicare Claims Processing Manual 30.6.6.

Brink reiterates that if the patient has a minor surgical procedure, which carries a l0-day global surgical period, you should not use 57 modifier when the physician performs an E/M on day of the minor procedure.

Myth 3: The physician’s decision to perform surgery doesn’t impact your modifier 57 use.

Truth: The 2017 CPT^® manual specifically states you should use modifier 57 when an E/M service results in the initial decision to perform the surgery.

Important: The E/M service must occur on the same day of or the day before the surgical procedure.

Using modifier 57 lets the provider receive credit for the additional work required to make the decision to do major surgery on the day of or day before that surgery, Witt says.

Caution: You should never report modifier 57 for an E/M service the day of or day before a preplanned or scheduled major (90-day) surgical procedure.  

“If the decision to do surgery is made before this time period, no modifier 57 is reported for the E/M service as all major procedures include preoperative clearance the day of or the day before surgery,” Witt says.