Neurosurgery Coding Alert

Turn to -57 for evaluations with major surgical procedures

If the neurosurgeon provides an E/M service that leads to the decision to perform a surgery with a 90-day global period on the same day, be sure to append modifier -57 to the E/M code. Otherwise, payers could bundle the evaluation into the surgery and deny your practice legitimate compensation.

3 Conditions Govern Your -57 Use

To apply modifier -57 (Decision for surgery), the services the surgeon performs must meet three conditions:

1. the E/M service must occur on the same day or the day before the surgical procedure;

2. the E/M service must have directly led to the surgeon's decision to perform surgery; and

3. the surgical procedure following the E/M must have a 90-day global period (that is, it must be a "major surgical procedure").

CPT doesn't have a set time frame for pre- and post-operative services. Medicare, however, directs 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," according to the Medicare Carriers Manual, section 15501.1. Most private (third-party) payers follow similar rules.

Best practice: Always append modifier -57 to the E/M service code, not the surgical procedure code, says Julia A. Appell, CPC, a coder with a general surgical practice in South Bend, Ind.

For example: The surgeon sees a patient with severe headache and nausea, and he quickly determines that the patient has a ruptured aneurysm and schedules immediate surgery (for instance, 61697, Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation).

In this case, you may report both the E/M service (such as 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.

Translation: In other words, the surgery was not previously planned at the time of the evaluation.

Start the Global One Day Prior to Procedure

The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure itself and includes one preprocedure E/M service for patient evaluation. 

For this reason, payers will normally bundle any E/M service the surgeon provides on the same day as, or the day before, a major procedure to the procedure itself, Appell says.

This means that if the surgeon has already scheduled surgery, and then provides a final E/M service for patient evaluation prior to surgery, you cannot charge separately for the service.

For example: The neurosurgeon schedules diskectomy (for example, 63077, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; thoracic, single interspace) for a patient with a ruptured intervertebral disk and nerve trapping.

On the day prior to surgery, the surgeon meets with the patient for a final evaluation to answer any additional 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 made the decision to perform surgery at a previous encounter - and because the E/M service occurs within the global period of the surgery - you should bundle this final presurgery E/M service into the diskectomy.

Don't try to "cheat": Merely scheduling pre-op services two or more days before surgery will not necessarily make the services payable.

Insurers may consider such services to be "screening" exams unless there is some specific indication, such as hypertension or diabetes.

Avoid Confusing -57 With -25

For same-day E/M services with procedures assigned a global period of less than 90 days, you should append 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, to the E/M service code, says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla. Medicare restricts modifier -57 to major surgeries only, and MCM specifically instructs carriers not to pay "for an E/M 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."

For example: A patient arrives at your neurosurgeon's office for a consult because of a sudden, severe headache.
 
The surgeon assigns a primary diagnosis of 784.0 (Headache), which she links to the consult (for example, 99243, Office consultation for a new or established patient ...). However, to rule out the possibility of meningitis or subarachnoid bleeding, the surgeon opts to perform a spinal tap (62270, Spinal puncture, lumbar, diagnostic) in addition to the E/M service.

In this case, you may report both the E/M service and the spinal tap. But because the spinal tap is not a major surgical procedure (the procedure has a zero-, rather than a 90-day global period), you should append modifier -25 - not modifier -57 - to 99243.
 
When in Doubt, Check the Fee Schedule
 
If you aren't sure of the global period of a particular procedure (and therefore whether you should append -25 or -57 to an E/M procedure provided at the same time as the surgery), consult the Medicare Physician Fee Schedule database.
 
The database is available as a free download from the CMS Web site and contains useful information on all current CPT codes, including RVUs, tips on proper modifier use and, of course, global period information.

To download the Physician Fee Schedule Database, visit www.cms.hhs.gov/physicians/pfs/. Scroll down until you find the "2005 National Physician Fee Schedule Relative Value File" link. Click on the link and follow the instructions to download the fee schedule database.