General Surgery Coding Alert

Medicare guidelines stipulate that evaluation and management services provided the day before or the day of a major surgery (i.e., a surgery with a 90-day global period) are included in the surgery's global package and are not separately reimbursable. If the preoperative exam prompted the decision for surgery, however, separate reimbursement is warranted and may be achieved if the visit is properly documented and modifier -57 (Decision for surgery) has been appended.

According to Medicare's global surgery rules, payment for surgical procedures includes the surgery itself (the intraoperative"" portion of the service)" as well as all postoperative care that does not require a return trip to the operating room for a duration of zero 10 or 90 days depending on the procedure. In addition the global surgical package generally includes all preoperative visits with the patient after the decision for surgery has been made beginning with the day before surgery for major procedures and the day of surgery for minor procedures i.e. procedures with zero- or 10-day global periods.

For example a patient previously scheduled to undergo laparoscopic cholecystectomy (47562 ... cholecystectomy) visits the surgeon the day before surgery for a final exam and to discuss last-minute concerns. In this case the E/M visit is included in the global surgical package for 47562 and you may not report it separately.

On occasion however the decision for surgery which is typically made days or weeks before may be made the day prior to or even the day of the operation. For instance the surgeon is asked to evaluate a patient for acute right-upper quadrant pain and tenderness and upon full evaluation decides the gallbladder must be removed and schedules an immediate laparoscopic cholecystectomy.

In such cases Medicare will allow separate reimbursement for the preoperative E/M service if certain conditions are met. The Medicare Carriers Manual (MCM) section 15501.1 instructs 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." The modifier must be appended to the E/M service code not the surgical procedure code. Modifier -57 need not be appended to E/M services that would normally fall outside the global surgical period e.g. an E/M visit five days before surgery.

Therefore in the above example of emergency lap chole the surgeon may report both the surgical procedure and the examination that led to the decision to perform the surgery as long as modifier -57 is appended to the appropriate E/M service code e.g. 99243 (Office consultation for a new or established patient ...). Failure to append modifier -57 to the E/M code will result in the E/M service being bundled into the global surgical package for 47562 leading to a loss in deserved reimbursement. In addition documentation should specifically note that the E/M service resulted in the decision for surgery.

With the exception of "starred" procedures (e.g. 10060* Incision and drainage of abscess [e.g. carbuncle suppurative hidradenitis cutaneous or subcutaneous abscess cyst furuncle or paronychia]; simple or single) all CPT codes in the range 10040-69979 are considered to include "global" care including a preoperative component. Thus any E/M service provided to make the decision for these "surgical" procedures should qualify for use with modifier -57. But 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.

"Note: Many payers including Medicare do not recognize the concept of a "starred" procedure and therefore include global care in these procedures as well. Ask your carrier for its individual guidelines.

If a significant separately identifiable E/M service is provided on the same date as a minor procedure including those with zero 10 or "XXX" global periods 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 should be appended to the E/M code. To qualify for separate reimbursement with modifier -25 the E/M service reported must go beyond the usual pre- intra-and postprocedure physician work associated with the procedure also billed. If a new symptom or condition prompted the E/M service report it. But Medicare does not require that the E/M service and procedure be linked to different diagnoses says Susan Callaway CPC CCS-P an independent coding and reimbursement specialist and educator in North Augusta S.C.

For example the surgeon sees a new patient in consultation for a breast mass and after performing a full history and exam determines that a biopsy is required e.g. 19102 (Biopsy of breast; percutaneous needle core using imaging guidance). Because 19102 includes a 0-day global period modifier -25 rather than modifier -57 is appended to the E/M code e.g. 99243-25.

Note: Global periods for all CPT codes can be found in column "N" of Medicare's Physician Fee Schedule. You may download the 2002 fee schedule free of charge from the CMS Web site www.cms.gov.

Only Medicare guidelines specifically limit modifier -57 to procedures with 90-day global periods says Sandy Page CPC CCS-P co-owner of Medical Practice Support Services a Denver-based billing and coding consultancy. Although most payers who adopt the CMS fee schedule also follow Medicare global surgery guidelines some private payers may allow modifier -57 for either major or minor surgeries. And some private payers still refuse to recognize modifier -25 despite CPT guidelines but will pay for modifier -57 claims (and vice versa) she says.

Because of variances among third-party payers be sure to contact all non-Medicare insurers prior to billing for their individual guidelines regarding both modifier -57 and modifier -25. If the insurer's rules differ from those specified by Medicare ask for its recommendations in writing. This will protect you during audits and provide an easily accessible reference for the future.

In the worst case some payers will refuse to recognize even modifier -57 if the E/M and surgical procedure occur on the same day. Instead the insurer will automatically "bundle" the decision-for-surgery visit to the global period of the operation claiming that payment for the E/M is included in the basic allowance for the procedure. Because third-party payers are not required to adhere to CPT or Medicare guidelines and if the insurer has specified that it doesn't reimburse for modifier -57 claims they are generally within their right to deny all such claims.

Barbara J. Cobuzzi CPC CPC-H MBA president of Cash Flow Solutions Inc. a Lakewood N.J. billing company believes that the relative values for surgeries do not include the initial E/M service where the decision for surgery is made and suggests appealing denials for modifier -57 claims. When appealing provide all documentation be sure to note that modifier -57 was used correctly based on Medicare and CPT guidelines and that the surgeon had to provide a full exam to determine the need for surgery.

Often payers will reimburse the claim upon appeal although a more proactive approach is to specify in any contracts with third-party payers that modifier -57 claims will be recognized and reimbursed based on CPT guidelines.