EM Coding Alert

Hint: Always communicate with your payers.

Not sure whether you are appropriately appending modifier 57 (Decision for surgery) on your claims? Follow these three tips from our pros to ensure correct reporting.

Tip 1: Double-check the documentation.

“Always ensure that the documentation supports the decision for surgery and is not supporting a preoperative clearance,” says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico. “If the surgeon makes the decision and does preoperative clearance at the same encounter, make sure that none of elements for the clearance are counted toward the level of service for the decision.”

Bonus physician documentation tip: Document each part of the encounter separately or clearly distinct.

Tip 2: Communicate with your payers.

You should always check with your payers on their policies regarding modifier 57, Witt says. She shares examples of such policies below:

Witt points out that according to Palmetto GBA, you should not submit modifier 57 with E/M codes that are clearly fornew patientslike 92002, 92004, 99201-99205, 99324-99328, 99281-99285, 99321-99323 and 99341-99345. Since these codes are new patient codes, they are automatically excluded from the global surgery package. So, they are reimbursed separately from surgical procedures. No modifier is required inorder for these codes to be separately reimbursed. These codes are also automatically excluded from the global surgery package.

When a surgeon is seeing a post-operative patient, Novitas and WPS state that if anE/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another unrelated procedure, you must bill the E/M service with both modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) and modifier 57.

Tip 3: Grasp the proper use of modifier 57.

“I have audited many records when an E/M is reported with a modifier 57, with the surgery is scheduled for two weeks away,” says Shannon O. DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, partner at DoctorsManagement, and president of NAMAS in Melbourne, Florida. “Keep in mind, this modifier is only appended when surgical intervention occurs within 24 hours of the E/M.”

It would necessarily be considered wrong if used, adds Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. However, it is not necessary when the visit and the surgery are spaced out.

Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey, emphasizes the importance of understanding modifier 57’s definition.

“You add modifier 57to the appropriate level of E/M service provided on the day before or day of surgery, in which the initial decision is made to perform major surgery,” Brink says.

Remember: You should consider only using modifier 57 with an E/M on the day before or the day of a major surgical procedure, never a minor surgical procedure, according to Brink.

Decode This Modifier 57 Scenario

Consider this coding scenario from Shannon O. DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, partner at Doctors Management, and president of NAMAS in Melbourne, Florida, about when to properly append modifier 57: A patient presents to a physician with abdominal pain. After providing the subjective interview of the patient to note his severity according to how he is feeling, and then examining him, the physician orders labs and radiology services to verify her thought process of the abdominal pain’s origination and to confirm the perceived plan of care.

The physician is convinced that the patient has appendicitis and requires surgery. The physician sends the patient straight to the hospital for surgical preparations and will meet him there in a few hours. If you do not append modifier 57 to the office visit encounter, then the bundling edits would prevent payment for the surgical services and the E/M service.