Gastroenterology Coding Alert

Question: We have many cases where the physician decides to perform a procedure later the same day or the next day after seeing a patient in the office. Which modifier will should I choose for these scenarios?

North Carolina Subscriber

Answer: You have a choice between 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) or 57 (Decision for surgery).

Your modifier 25 claims should meet all of the following criteria:

• The E/M occurs on the same day as the procedure
• The procedure following the E/M is minor (has a zero or 10-day global period)
• The E/M service is both significant and separately identifiable from any inherent E/M component that the procedure involves
• The same physician (or one with the same tax ID) provides the E/M service and the surgical/endoscopic procedure.

Note that the diagnosis associated with the E/M service can be the same as the diagnosis associated with the same-day procedure, which means that the E/M prompted the follow up procedure. Or, the diagnosis associated with the E/M service can be different than the diagnosis associated with the same-day procedure, meaning that the E/M was for a significant problem unrelated to the procedure.

Use modifier 57 if the claim meets all of the following criteria:

• The E/M occurs on the same day of or the day before the procedure
• The intended procedure following the E/M has a 90-day global period
• The E/M service directly prompted the physician’s decision to perform the procedure
• The same physician (or another physician with the same tax ID) provided the E/M service and the procedure.

Because modifier 57 claims involve an E/M service that results in a decision for surgery, you would expect to see the same diagnosis code for both the E/M and the surgical/endoscopic procedure. The physician would not make a decision for surgery based on a significant problem unrelated to the procedure.