General Surgery Coding Alert

Question: The definition of modifier 57 is “decision for surgery,” so why do I get notices that this modifier is wrong when I append it to an E/M that leads to a skin biopsy?

Iowa Subscriber

Answer: The answer has to do with global days. For those payers following Medicare rules, you should append modifier 57 (Decision for surgery) to an E/M code when you report the E/M on the same date as a major surgical procedure or on the day before. A major surgical procedure is one with 90 global days. You can expect to find that skin biopsies have 0 global days. Always check before coding.

Dig deeper: Modifier 57 applies when the surgeon performs the E/M to determine whether a major procedure, such as cholecystectomy, is necessary for the patient and when the E/M is distinct from the usual pre-work performed for a procedure.

Minor procedures: Services with 0- or 10-day global periods (minor procedures) include payment for the decision to perform surgery, so you should not report a separate E/M for that process. Remember that many endoscopic and transvascular procedures have 0 global days even when the work is quite extensive, because there is no large surgical incision that requires lengthy healing.

If the patient does have a separately reportable E/M on the date of the minor procedure, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service). You also may append 25 to a distinct E/M performed on the same date as an XXX global service (meaning that the code represents only the service or procedure itself, along with any minor inherent E/M component).

Resource: Check out the Medicare Claims Processing Manual, Chapter 12, Section 30.6.6, “Payment for Evaluation and Management Services Provided During Global Period of Surgery,” and Section 40.2, “Billing Requirements for Global Surgeries,” to see the wording straight from the source.