Internal Medicine Coding Alert

Question: We attached modifier -57 to an E/M service that resulted in a decision to remove a lesion. Our Medicare carrier rejected our claim. What did we do wrong?

Virginia Subscriber

Answer: You should attach modifier -57 (Decision for surgery) when an E/M service, such as 99214 (Office or other outpatient visit ... established patient ...), results in a decision for major surgery during the patient preoperative period. The preoperative period on a major surgery includes the day of and the day prior to the procedure. Typically, your internist should order an emergency procedure or surgery, not a scheduled or elective surgery.
 
Medicare requires modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when your physician performs an E/M service and a minor procedure on the same date of service. Remember that if the global fee period is greater than 10 days, carriers consider the surgery a major procedure, so you should use modifier -57 on the E/M service.
 
 - Answers for You Be the Coder and Reader Questions were provided by Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.; and Bruce Rappoport MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for RCH Healthcare Advisors LLC, a Fort Lauderdale, Fla.-based healthcare consulting company.