General Surgery Coding Alert

Assign 57, not 25, for E/M prior to a major surgical procedure

If your surgeon provides an E/M service on the same date as, or during the global period of, another procedure or service, you-re going to have to append a modifier to the  E/M code. To be sure of your choice--and to differentiate between modifiers 25 and 57--ask yourself two questions.

Question 1: Does the E/M Follow Another Service?

When an E/M service occurs during a postoperative global period, but for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code. By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the E/M service is not included in the global surgical package of the previous procedure, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Remember: You cannot bill separately for related services during the global period. Routine postoperative care during the global period is included in the global surgical package.

Example: A long-term patient has two toes amputated. During postoperative rounds, the surgeon notes an ulcer on the calf region of the same leg, which requires dressing, antibiotics and other attention.

The surgeon performs an evaluation for this new, distinct problem (that is, the ulcer is unrelated to the toe amputation). In this case, you should append modifier 24 to the correct E/M code (for example, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

Learn more: Look to next month's General Surgery Coding Alert for additional information on modifier 24.

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Modifier 24: Conditions for Use

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) who performed the previous procedure provides the E/M.

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Question 2: -Major- or -Minor- Procedure?

When the surgeon decides to perform another procedure during an E/M service and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately. Depending on the length of the procedure's global period, you should append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) to the appropriate E/M code.

Minor procedures mean 25: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with zero, 10 or -XXX- global periods, you should append modifier 25 to the E/M code, says Linda Parks, MA, CPC, CCP, coding specialist in Marietta, Ga.

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Modifier 25: Conditions for Use

When appending modifier 25, the E/M service must meet these requirements:

- The E/M is significant and separately identifiable from any -inherent- E/M component included with other services/procedures you report on the same day.

- The E/M may be related or unrelated to other procedures/services you report on the same day.

- The service/procedure the surgeon provides on the same day as the E/M service should have a zero, 10 or -XXX- global period.

- The same physician bills the E/M and other procedures/services on the same day.

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Get all the facts: For complete information on modifier 25, see -3 Field-Tested Ways to Ease Your Modifier 25 Claims- included with this issue.

90-Day Global = Modifier 57

When the surgeon arrives at the decision to perform major surgery (that is, a surgery with a 90-day global period) and provides the surgery that day or the next day, you should append modifier 57 to the E/M code, according to Medicare guidelines outlined in the Medicare Carriers Manual (section 15501.1).

Example: While building a gym set for his children in the back yard, an established patient experiences sharp pain in his lower abdomen. After several hours of

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Modifier 57: Conditions for Use

To append modifier 57 properly, you must remember these points:

- The E/M service occurs the day of or the day before a major surgical procedure (a procedure with a 90-day global period).

- The E/M service must prompt the surgical procedure that follows.

- The E/M service must be related to the procedure that follows.

- The same physician (or tax ID) provides the E/M service and the surgical procedure.

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persistent pain and nausea, he arrives for an emergency office visit. Upon examination, the surgeon finds that the patient has suffered a serious hernia and schedules immediate surgery for repairs.

Although the global surgical package for 49650 (Laparoscopy, surgical; repair initial inguinal hernia) includes one presurgical E/M service, in this case the office visit led to the decision to perform surgery. Therefore, you may report it separately with modifier 57 at the level supported by documentation, Hammer says.

You should report both the surgical procedure (49650) and the examination that led to the decision to perform the surgery (for example, 99214). You should append modifier 57 to 99214 to indicate that this E/M service led to the decision for surgery.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package for 49650, leading to a loss in reimbursement.