Gastroenterology Coding Alert

Modifiers 57 and 24 could be essential, depending global periods.

Every gastroenterology practice is familiar 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), but that doesn’t mean it’s your sole choice for reporting an E/M service along with a procedure.

In fact, when your physician performs a significant and separately identifiable E/M service that falls within a procedure’s 90-day global period — a major procedure — modifier 25 is not appropriate. To ensure that you don’t miss out on payment due to using the wrong modifiers, check out the following primer on the alternative modifiers.

Post-Op? Use Modifier 24

Sometimes, a physician examines a patient within the 90-day global period of a major procedure, but for a different problem.

Although GI physicians don’t frequently perform surgeries with 90-day globals, it’s important to understand how to report these when they do arise.

For instance, suppose the physician performs an internal hemorrhoid destruction using cautery (46930, Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency). This procedure carries a 90-day global period. A month later, the same doctor sees the patient for a stomach problem. That might be when you call on modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

When you report modifier 24, the E/M service must meet these criteria:

• The E/M service occurs during the postoperative period of another procedure.
• The current E/M service is unrelated to the previous procedure.
• The same physician (or tax ID or same group and specialty) who performed the previous procedure provides the E/M.

See it in practice: Suppose your GI physician performs hemorrhoid destruction and reports 46930. Two weeks later, the patient comes to the office complaining of mouth sores. The physician documents a 25-minute visit evaluating the mouth sores.

In this case, you’d report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter) with modifier 24 appended, along with the diagnosis code for the mouth sores.

Remember: Medicare and many other payers have very specific guidelines for what qualifies as “related” to the original procedure and what doesn’t. For instance, Medicare will always treat postoperative infections as related to (and therefore, included in the global surgical package of) the initial surgery — unless your gastroenterologist must return the patient to the operating room to deal with an infection. Modifier 24 should only be used when the subsequent E/M service is unrelated to the original procedure.

Same Day or Day Before? Append Modifier 57

Occasionally, a physician wants to rush a patient into the operating room as a result of an exam. When your physician decides to perform a minor procedure as a result of an E/M service, you append modifier 25. When it’s a major procedure the doctor performs the same or next day, you’ll call on modifier 57 (Decision for surgery).

You should append modifier 57 to an E/M service that occurs on the same day, or on the day before, a major surgical procedure, and which results in the physician’s decision to perform the surgery. CMS guidelines identify a major surgical procedure as any procedure with a 90-day global period. Note that the global period for a major surgical procedure begins one day prior to the procedure itself.

Direct from the source: The Medicare Claims Processing Manual, Chapter 12, Section 30.6.6.C, instructs carriers to “pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT^® modifier 57 to indicate that the service resulted in the decision to perform the procedure.”

Don’t look for a loophole: Scheduling pre-op services two or more days before surgery will not necessarily make the services payable without a modifier. Insurers may consider such services to be screening exams unless there is some specific indication, such as hypertension or diabetes. The documentation for these visits must substantiate medical necessity and not just a routine requirement of the physician or the hospital.

To properly append modifier 57, remember that the E/M service must be related to the procedure that follows; and the same physician (or tax ID) must provide the E/M service and the surgical procedure.