General Surgery Coding Alert

Stick with -25 for evaluations with less-intensive services If your general surgeon provides an evaluation and management service that leads to the decision to perform a surgery with a 90-day global period on the same day, be sure to append modifier -57 to the E/M code. Otherwise, payers could bundle the evaluation into the surgery and deny your practice legitimate compensation. 3 Conditions Govern Your -57 Use To apply modifier -57 (Decision for surgery), the services the surgeon performs must meet three conditions:

1. the E/M service must occur on the same day of or the day before the surgical procedure;

2. the E/M service must have directly led to the surgeon's decision to perform surgery; and

3. the surgical procedure following the E/M must have a 90-day global period (that is, it must be a "major surgical procedure"). CPT doesn't have a set time frame for pre- and post-operative services. Medicare, however, directs carriers to "Pay for an E/M 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 was for the decision to perform the procedure," according to the Medicare Carriers Manual, section 15501.1. Most private (third-party) payers follow similar rules.

Best practice: Always append modifier -57 to the E/M service code, not the surgical procedure code, says Julia A. Appell, CPC, a coder with a general surgical practice in South Bend, Ind.

For example: The surgeon receives a request to evaluate a patient for acute right-upper quadrant pain and tenderness. Following a full evaluation, the surgeon decides to remove the gallbladder and schedules an immediate laparoscopic cholecystectomy (47562, Laparoscopy, surgical; cholecystectomy).

In this case, the surgeon may claim both the surgical procedure (47562) and the examination that led to the decision to perform the surgery (for example, 99243, Office consultation for a new or established patient ...). Because the cholecystectomy is a major procedure, you should append modifier -57 to 99243. And documentation should specifically note that the E/M service resulted in the decision for surgery.

Translation: In other words, the surgeon did not plan the cholecystectomy at the time of the evaluation, and therefore you may report the evaluation separately as the service that led to the decision to perform surgery. Start Global One Day Prior to Procedure The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure itself and includes one preprocedure E/M service for patient evaluation.
 
Therefore, payers will bundle any E/M service the surgeon provides on the same day as, or the day before, a major procedure to the procedure itself, Appell says.

This means that if the surgeon has already scheduled surgery, [...]