Neurosurgery Coding Alert

Medicare guidelines stipulate that E/M services provided the day before or the day of a major surgery (a surgery with a 90-day global period) are included in the surgery's global package and are not separately reimbursable. If the preoperative exam prompted the decision for surgery, however, separate reimbursement is warranted and may be achieved if the visit is properly documented and modifier -57 (Decision for surgery) is appended to the appropriate E/M service code.

According to Medicare's global surgery rules, payment for surgical procedures includes the surgery itself (the "intraoperative" portion of the service), as well as all postoperative care that does not require a return trip to the operating room for a duration of zero, 10 or 90 days, depending on the procedure. In addition, the global surgical package generally includes all preoperative visits with the patient after the decision for surgery has been made, beginning with the day before surgery for major procedures and the day of surgery for minor procedures (procedures with zero- or 10-day global periods).
 
For example, a patient previously scheduled to undergo diskectomy (e.g., 63077, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; thoracic, single interspace) meets with the surgeon the day before surgery for a final examination and to discuss last-minute questions and concerns. The E/M visit is included in the global surgical package for 63077 and may not be separately reported.
 
On occasion, the decision for surgery, which is typically made days or weeks before, may be made the day prior to or even the day of the operation. For instance, the surgeon is called to the emergency department (ED) to examine an automobile accident victim with a closed in head injury. Upon full evaluation, the surgeon admits the patient and immediately operates to evacuate a subdural hematoma (61108, Twist drill hole for subdural or ventricular puncture; for evacuation and/or drainage of subdural hematoma).
 
In such cases, Medicare will allow separate reimbursement for the preoperative E/M service if certain conditions are met. The Medicare Carriers Manual (MCM), section 15501.1, instructs carriers to "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." The modifier must be appended to the E/M service code, not the surgical procedure code. Modifier -57 need not be appended to E/M services that would normally fall outside the global surgical period (e.g., an E/M visit five days prior to surgery).
 
Therefore, in the above example of the accident victim with subdural hematoma, the surgeon may report both the surgical procedure (61108) and the examination that led to the decision to perform the surgery, as long as modifier -57 is appended to the appropriate E/M service code (e.g., 99223, Inpatient hospital care, per day, for the evaluation and management of a patient ). Failure to append modifier -57 to the E/M code will result in the E/M service being bundled into the global surgical package for 61108, leading to a loss in deserved reimbursement. In addition, documentation should specifically note that the E/M service resulted in the decision for surgery.

With the exception of "starred" procedures (e.g., 62270*, Spinal puncture, lumbar, diagnostic), all CPT codes in the range 10040-69979 are considered to include "global" care, including a preoperative component. Thus, any E/M service provided to make the decision for these "surgical" procedures should qualify for use with modifier -57. Medicare restricts modifier -57 to major surgeries only, however, and the MCM 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."
 
If a significant, separately identifiable E/M service is provided on the same date as a minor procedure, including those with zero, 10 or "XXX" global periods, modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), rather than modifier -57, should be appended to the E/M code. To qualify for separate reimbursement with modifier -25, the E/M service reported must go beyond the usual pre-, intra- and postprocedure physician work associated with the procedure also billed. If a new symptom or condition prompted the E/M service, it should be reported. However, Medicare does not require that the E/M service and procedure be linked to different diagnoses, explains Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.
 
For example, the surgeon sees a new patient who has head trauma. The patient undergoes a thorough examination and is admitted to the hospital for continued intracranial-pressure (ICP) monitoring. In this case, because documentation supports billing for a separate E/M service, both the admission (99223, Initial hospital care, per day, for the evaluation and management of a patient) and the ICP monitoring (61107*, Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording device) may be reported. Because 61107* includes a 10-day global period, modifier -25 rather than modifier -57 is appended to the E/M code.
 
Note: Global periods for all CPT codes can be found in column "N" of Medicare's Physician Fee Schedule. The 2002 fee schedule may be downloaded free of charge from the CMS Web site at: www.hcfa.gov/stats/rvucrst.htm.

Only Medicare guidelines specifically limit modifier -57 to procedures with 90-day global periods, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a Denver-based billing and coding consultancy. Although most payers who adopt the CMS fee schedule also follow Medicare global surgery guidelines, some private payers may allow modifier -57 for either major or minor surgeries. In addition, some private payers still refuse to recognize modifier -25 despite CPT guidelines, but will pay for modifier -57 claims, she notes.
 
Because of variances among third-party payers, before billing, be sure to contact all non-Medicare insurers for their individual guidelines regarding both modifier -57 and modifier -25. If the insurer's rules differ from those specified by Medicare, ask for its recommendations in writing. This will protect you during audits and provide an easily accessible reference for the future.
 
In the worst case, some payers will refuse to recognize even modifier -57 if the E/M and surgical procedure occur on the same day. Instead, the insurer will automatically "bundle" the decision-for-surgery visit to the global period of the operation, claiming that payment for the E/M is included in the basic allowance for the procedure. Because third-party payers are not required to adhere to CPT or Medicare guidelines and if the insurer has specified that it doesn't reimburse for modifier -57 claims they are generally within their right to deny all such claims.
 
Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company, believes that the relative values for surgeries do not include the initial E/M service where the decision for surgery is made, and suggests appealing denials for modifier -57 claims. When appealing, provide all documentation and be sure to note that modifier -57 was used correctly per Medicare and CPT guidelines and that the surgeon had to provide a full exam to determine the need for surgery. Often payers will reimburse the claim upon appeal although a more proactive approach is to specify in any contracts with third-party payers that modifier -57 claims will be recognized and reimbursed per CPT guidelines.