General Surgery Coding Alert

Timing is everything to differentiate these modifiers.

When your surgeon performs an E/M service and a procedure on the same day, you just might get to collect pay for both. In fact, the key to proper pay is just a modifier away — but coders often miss the nuances that help them choose the right one.

Take the following tutorial from our experts and you’ll learn how to distinguish two modifiers that can ensure appropriate reimbursement for E/M and surgery on the same date of service.

Identify Modifier Choices

Depending on the circumstances, you may be able to report both an E/M and a procedure code on the same date if you append one of the following modifiers:

• 57, Decision for surgery
• 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

Distinguish 57, 25: The number of global days associated with the procedure is a key factor in determining whether to use modifier 57 or 25.

“Note that the 57 modifier applies to what Medicare classifies as major surgeries as identified in the Medicare Physician Fee Schedule,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. “That means it has a 90-day postoperative global period.”

Coder Gaye Pratt, RMM, RMC, agrees. “If the procedure performed has a 90 day global period, use the 57 modifier,” she says. That’s also true for a 10 day global procedure, but not for a zero-day service, which would take the 25 modifier.

Note: If the other service has an XXX global period, the global concept does not apply and you don’t need a modifier to report the procedure with an E/M service. Coders often get confused and erroneously think they have to apply modifier 25 anytime another service, such as an x-ray, occurs on the same date as an E/M. »»

Focus 57 Reporting

Modifier 57 applies when the physician performs an E/M service, and based on the findings of this examination, decides that a major procedure is necessary the same or following day. The surgeon must also document how the E/M service is distinct from the usual pre-operative work associated with the procedure.

For instance: A new 32 year old patient presents with fever, vomiting, acute umbilical pain at the site of a swollen, red, abdominal protrusion. The surgeon performs an expanded problem focused history and exam and diagnoses a strangulated umbilical hernia, which he determines requires immediate open surgery to avoid tissue death and further infection.

Solution: You should report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making) with modifier 57, and 49587 (Repair umbilical hernia, age 5 years or older; incarcerated or strangulated).

Caution: Once the physician decides on surgery, the unrelated E/M service ends, says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M. Any care that relates directly to performing the procedure — such as informed consent, or explaining the procedure to the patient — does not count toward elements of the separate E/M.

Bust this myth: Contrary to popular belief, claims with modifier 57 do not require you to report different diagnoses for the E/M service and the separate procedure, Witt says. But the documentation must clearly support that the E/M represents a separate, service that is not part of the typical pre-op exam.

Watch for ‘25’ Opportunities

For an E/M on the same date as a non-major surgical procedure, you should turn to modifier 25 instead of 57.

Example 2: During an established patient problem-focused history and examination of a third degree on the forearm, the surgeon determines the need to perform an escharotomy. The surgeon also performed an exam to determine the extent of nerve damage in the arm, and determined the need to send the patient to a specialist for suspected nerve impairment.

The surgeon proceeds to create a surgical incision into the eschar to release the pressure and divide the inelastic mass of burnt tissue that was causing accumulation of fluid in the tissue space, threatening further loss of tissue viability.

Solution 2: You should report the E/M service using an appropriate code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making). Code the escharotomy as 16035 (Escharotomy; initial incision).

Include modifier: You’ll need to append modifier 25 to 99212 to indicate that the E/M service is a distinct, separately identifiable exam because the escharotomy procedure has a 0-day global period.