General Surgery Coding Alert

Question: Our surgeon saw an established patient in the office to examine a third-degree burn on the right calf. The surgeon determined that the tight burn surface was impacting circulation and required an escharotomy, which he performed. Can we report an E/M and the escharotomy, and should we use modifier 57 since the visit included a decision for surgery?

Texas Subscriber

Answer: You can separately report both the E/M and the escharotomy, but you should not use modifier 57 (Decision for surgery).

Do this: Code the escharotomy as 16035 (Escharotomy; initial incision). Also report the office visit, using a 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) with modifier 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).

Here’s why: The number of global days associated with the procedure is a key factor in determining whether to use modifier 57 or 25. For procedures with a 90-day global period, turn to 57, but for procedures with a 10- or zero-day global period (minor procedures) you may use modifier 25.

More tips: You should also meet the following criteria before using modifier25:

• The surgeon’s documentation proves that he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the procedure
• The E/M service occurs for the same patient on the same calendar day as the procedure
• You’re reporting an E/M service using a code from the range 99201 through 99499.