General Surgery Coding Alert

Question: When should I use modifier -57 (Decision for surgery)? Does this modifier apply to patients admitted to the hospital who go directly to the operating room? Does it apply to patients who receive laceration repair, for instance?

Kansas Subscriber

Answer: You should append modifier -57 when the E/M service the surgeon performed resulted in the decision for surgery - for example, a surgeon's examination of a patient reveals an immediate need for surgical intervention.
 
However, for Medicare and payers that follow Medicare rules, you should only append modifier -57 to procedure codes that have 90-day postoperative periods. And, generally, laceration repair codes (such as 13100, Repair, complex, trunk; 1.1 to 2.5 cm) have 10-day global periods (and usually don't require a trip to the operating room). Only extensive repair codes, such as those involving tissue transfer (for example, 14000, Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less), include a 90-day global period.
 
Tip: To determine global periods for individual codes, consult the Medicare Physician Fee Schedule Database, available free at the CMS Web site: www.cms.gov. Use the "search" function to locate "2004 Physician Fee Schedule."
 
For procedures with 10- or zero-day global periods, you may report a separately identifiable E/M service along with a procedure by appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M code.
 
Therefore, if the surgeon sees a patient in the hospital, performs a separate E/M and decides that the patient requires immediate laceration repair, you may report the appropriate E/M code (such as an inpatient consult code) with modifier -25 appended. You should also report the correct laceration repair code(s) (for instance, 13101, Repair, complex, trunk; 2.6 cm to 7.5 cm and +13102, ...each additional 5 cm or less [list separately in addition to code for primary procedure]).