Neurosurgery Coding Alert

When an E/M service prompts a -major- surgical service, you should append modifier 57, rather than modifier 25, to gain separate payment for the E/M service. Follow our checklist to apply modifier 57 correctly and avoid the 25/57 confusion.

Look for a 90-day Global

You should apply modifier 57 (Decision for surgery) only when an E/M service precedes a surgical procedure with a 90-day global period. Medicare restricts modifier 57 to major surgeries, and the Medicare Internet Only Manual (IOM), section 40.2, specifically instructs carriers not to pay -for an evaluation and management service billed with the CPT modifier 57 if it was provided on or the day before a procedure with a zero- or 10-day global surgical period.-

In neurosurgery practice, many of the most common procedures, such as laminectomies, arthrodesis and instrumentation placement, are -major surgical procedures- with 90-day global periods.

For a significant and separately identifiable E/M service that occurs on the same day as a minor procedure (any procedure with a zero- or 10-day global period), you should append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) rather than modifier 57, says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician educator for the department of surgery at the University of Pittsburgh Medical Center.

Minor procedures include spinal taps (62270), many types of injections (such as trigger point injections 20552 and 20553), vertebroplasty (22520-22522) and kyphoplasty (22523-22525).

Tip: For more information on global periods, see -Global Periods Made Easy- in this issue.

You may append modifier 57 only if the E/M service preceding the surgery directly led to or prompted the decision for surgery. In such a case, the surgeon would see the patient for an E/M service and schedule the surgery for either the same or the next day.

Direct from CMS: The IOM, section 40.2, directs carriers, -Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier 57 to indicate that the service was for the decision to perform the procedure.-

Warning: If the physician has already scheduled surgery and then provides a final E/M service prior to surgery, you cannot charge separately for the service.

Example: The surgeon schedules laminectomy (for example, 63047) for a patient with spinal stenosis (724.02). A week later on the day before surgery, the surgeon meets with the patient for a final evaluation, to answer any questions the patient has and to provide additional instructions for recovery.

In this case, you cannot charge separately for the E/M service. Because the surgeon already decided to perform surgery at a previous encounter -- and because the service occurs within the surgery's global period -- you should bundle this final pre-surgery E/M into the laminectomy.

E/M Must Occur Day of or Day Before Procedure

The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure and includes one preprocedure E/M service for patient evaluation. This means that payers will routinely bundle any E/M service the surgeon provides on the same day as, or the day before, a major procedure to the procedure itself, unless the service meets the requirements for -- and you apply -- modifier 57.

Don't try to cheat: Merely scheduling pre-op services two or more days before surgery will not necessarily make the services payable, Hvizdash says. Insurers may consider such services to be screening exams or hospital requirements, and unless there is some specific indication, such as hypertension or diabetes, these visits are not medically necessary. The documentation for these visits must substantiate medical necessity and not just a routine/requirement of the physician or the hospital.

Restrict 57 to E/M Services

You should always append modifier 57 to the E/M service code, not the surgical procedure code.

Example: The surgeon sees a patient with severe headache and nausea. He quickly determines that the patient has a ruptured aneurysm and schedules immediate surgery (e.g., 61697, Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation).

In this case, you may report both the E/M service (e.g., a hospital admission, 99223, Initial hospital care, per day, for the evaluation and management of a patient ...) and the intracranial aneurysm surgery because the E/M service resulted in the decision to perform the surgery.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package for 61697.

E/M, Procedure Must Fall Under Same Tax ID

The same physician (or a member of the same group practice billing under the same tax identification) must provide both the E/M service and the surgical procedure. A different physician providing an unrelated E/M service to a patient prior to a scheduled or unscheduled surgery need not worry about bundling issues, and therefore would not need to append modifier 57.