Neurosurgery Coding Alert

Assign 57, not 25, for E/M prior to major surgical procedure

If your surgeon provides a billable E/M service on the same date as, or during the global period of, another procedure or service, you should append a modifier to the E/M code. If the E/M occurs during a global period, chances are you-ll reach for modifier 24.

To be sure of your choice--and to differentiate between modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 57 (Decision for surgery)--ask yourself these questions.

Question 1: Does the E/M Follow Another Service?

When an E/M service occurs during a postoperative global period, but for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code.

By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a problem that requires cognitive effort beyond what was paid in the global package of the previous surgery, and therefore should allow payment, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Remember: You cannot bill separately for related services during the global period. All payers include routine postoperative care during the global period in the global surgical package.

Example: A patient undergoes posterior laminectomy (63045, Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; cervical). Two months later, the patient falls, leading to a new injury.

The surgeon performs an evaluation for this new, distinct problem. In this case, you should append modifier 24 to the correct E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

Learn more: For additional information on modifier 24, see -Call on 24 for Complication Evaluations--Maybe- later in this issue.

Question 2: -Major- or -Minor- Procedure?

When the surgeon decides to perform another procedure during an E/M service, and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately. Depending on the length of the global period associated with the procedure, you should append either modifier 25 or modifier 57 to the appropriate E/M code.

Minor procedures mean 25: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with zero-day, 10-day or -XXX- global periods, you should append modifier 25 to the E/M code, says Linda Parks, MA, CPC, CCP, coding specialist for GI Diagnostics Endoscopy Center in Marietta, Ga.

Example: The surgeon sees a new patient who has head trauma. The surgeon examines the patient and admits him to the hospital for continued intracranial-pressure (ICP) monitoring.

Modifier 24: Conditions for Use

When you report modifier 24, the E/M service must meet these criteria:

- The E/M service occurs during the postoperative period of another procedure. 
- The E/M service is unrelated to the previous procedure.
- The same physician who performed the previous procedure provides the E/M.

Modifier 25: Conditions for Use

When you append modifier 25, the E/M service must meet these requirements:

- The E/M service is significant and separately identifiable from any -inherent- E/M component included with other services/procedures you report on the same day.
- The E/M may be related or unrelated to other procedures/services you report on the same day.
- The service/procedure the surgeon provides on the same day as the E/M service should have a zero-day, 10-day or -XXX- global period.
- The same physician performs the E/M and other procedures/services on the same day.

Modifier 57: Conditions for Use

To append modifier 57 properly, remember these points:

- The E/M service occurs the day of a surgical procedure (or also the day before a major procedure with a 90-day global period).
- The E/M service must prompt the surgical procedure that follows.
- The E/M service is related to the procedure that follows.
- The same physician provides the E/M service and the surgical procedure.

In this case, because documentation supports billing for a separate E/M service, you may report 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). Because 61107 includes a 10-day global period, you should append modifier 25--rather than modifier 57--to the E/M code.

Tip: To determine whether a service is separately identifiable, you should identify which of the following questions the visit is designed to answer. Addressing the question -Is the procedure (still) the correct treatment for the patient's condition?- supports that the E/M service is separate. The question -Is the patient OK to undergo a planned procedure today?- means the service is part of the global care.

The whole story: For complete information on modifier 25, see -Call on 25 for Same-Day Service and Significant E/M,- Neurosurgery Coding Alert, January 2006.

90-Day Global = Modifier 57

When the surgeon elects to perform major surgery (that is, a surgery with a 90-day global period) and provides the surgery that day or the next day, you should append modifier 57 to the E/M code, according to Medicare guidelines outlined in the Medicare Carriers Manual (section 15501.1).

Example: In the emergency department (ED), the surgeon examines 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).

You should report both the surgical procedure (61108) and the examination that led to the decision to perform the surgery (for example, 99223). You should append modifier 57 to 99223 to indicate that this E/M service led to the decision for surgery.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M into the global surgical package for 61108, leading to a loss in deserved reimbursement.