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, and then provides a final E/M service prior to surgery, you cannot charge separately for the service.

For example: The surgeon schedules cholecystectomy (47562) for a patient with a diseased gall bladder. On the day prior to surgery, the surgeon meets with the patient for a final evaluation, to answer any questions the patient has and to provide additional instructions for recovery.
 
In this case, you cannot charge separately for the E/M service. Because the surgeon already decided to perform surgery at a previous encounter - and because the E/M service occurs within the global period of the surgery - you should bundle this final presurgery E/M service into the cholecystectomy.

Don't try to "cheat": Merely scheduling pre-op services two or more days before surgery will not necessarily make the services payable.

Insurers may consider such services to be "screening" exams unless there is some specific indication, such as hypertension or diabetes.

Avoid Confusing -57 With -25

For same-day E/M services with procedures assigned a global period of less than 90 days, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), rather than modifier -57, to the E/M service code, says Susan Callaway, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C. Medicare restricts modifier -57 to major surgeries only. And the MCM specifically instructs carriers not to pay "for an evaluation and management service billed with the CPT modifier -57 if it was provided on or the day before a procedure with a zero- or 10-day global surgical period."

For example: The surgeon sees a new patient in consultation (99243) for a breast mass. After performing a full history and exam, the surgeon decides to take a fine needle aspiration (10021, Fine needle aspiration; without imaging guidance).

In this case, you may report both the E/M service and the aspiration. But because the aspiration is not a major surgical procedure (the procedure has a zero-day, rather than a 90-day, global period), you should append modifier -25 - not modifier -57 - to 99243. Therefore, you should report 10021, 99243-25.
 
When in Doubt, Check the Fee Schedule Database
 
If you aren't sure of the global period of a procedure (and therefore whether you should append -25 or -57 to an E/M procedure provided at the same time as the surgery), consult the Medicare Physician Fee Schedule database.
 
The database is available as a free download from the CMS Web site and contains useful information on all current CPT codes, including RVUs, tips on proper modifier use and, of course, global period information.

To download the Physician Fee Schedule Database, visit www.cms.hhs.gov/physicians/pfs/. Scroll down until you find the link labeled "2005 National Physician Fee Schedule Relative Value File." Click on the link and follow the instructions to download the database.