Neurosurgery Coding Alert

Append modifier 57 when same physician provides E/M service and performs procedure.

Modifier 57 (Decision for surgery) may leave you perplexed if you do not have clarity about when you can most appropriately use it. You are likely to face challenges when there are variations in definitions of global periods. 

Know Your Payer's Definition of a Global Period

One potential cause of modifier 57 denials is that payers may have different definitions of a global period.

CMS defines a global surgical package as "all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the pre-operative, intra-operative and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician" (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf).

CMS, along with most other payers, assigns a procedure or service to one of the following types of global surgical packages:

• 0-day: Only the day of the surgery is a part of the package
• 10-day: The day of surgery and 10 days following the surgery, totaling an 11-day package.
• 90-day: One day before the surgery, the day of the surgery, and 90 days following the surgery, totaling a 92-day package.

You should use modifier 57 only on an E/M code that represents the decision to perform a procedure with a 90-day global, according to Medicare. In neurosurgery, the 90 days global period applies to some add-on codes - for instance, +63048 (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; each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]). Because add-on procedures are by definition related to another procedure, they are always included in the global period of the parent code, which is the primary, related surgical procedure. Many of your other commonly used procedure codes, like percutaneous procedures, typically have a 0-day global, and in those cases modifier 57 would not be appropriate.

"In circumstances when a separately identifiable E/M service is provided at which time a percutaneous procedure is determined to be medically necessary and performed that day, one may report modifier 25 on the separately identifiable E/M service," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

"Both Medicare and CPT® include, for their procedures with a 90-day global, the day of or day before surgery. But many other payers, including many of the Medicaid programs, don't include a day before surgery, so the only thing they're concerned about is E/M on the same day as the surgery," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, audit manager at CHAN Healthcare in Vancouver, Wash.

What to do: Once you sign a contract with a payer, you're obligated to know their rules, including their definition of a global period. If you don't follow their billing rules, you're most likely losing money by not billing for payable services or by spending money on appeals.

When in doubt, experts suggest following the CPT®/CMS rules. "I do know that the different payers have different ideas about global days," says Suzan Berman (Hauptman), MPM, CPC, DEDC, CEMC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn. "I tend to be conservative and use the modifier as it has been directed by CPT®/CMS as the day before surgery or the day of surgery when the decision was made at that visit."

"Some payers have a longer preoperative global period up to two weeks before surgery," Przybylski says.  "It is important to be familiar with each payers rules regarding the global period so that modifiers may be correctly applied."

Good practice: AMA suggests keeping a health insurer reference log where you can include the payer's global period definition, so that it's at your fingertips when you are coding. 

Be Aware of Possible Problems with Payer's Claims-Editing Software 

When you have a continually denied claim for an E/M service and surgery, when the decision for surgery was made as a result of the E/M service, the reason for the denial may be because your codes were mistakenly bundled. The bundling may happen due to the payer's claims-editing software not recognizing modifier 57. 

"This issue has been a frequent area of complaint," Przybylski says. "Make sure your documentation correctly reflects the separately identifiable E/M service and that the decision for surgery was made as a result of that E/M service in order to support an appeal if the claims-editing software causes your service to be denied."

What to do: Talk to the payer to determine if the denial is the result of a software limitation or the denial is based on a billing rule. Bucknam recommends doing three things when a payer continually denies your claims:

• Talk to your payer representative to find out what you can do to get your claim approved. If they say their policy is to not pay for an E/M service on the day of a procedure, then take note of that, and don't waste your time on what will never be paid.
• If you learn that the payer will only pay the E/M with a modifier 57 on appeal, ask them if you can group your E/Ms together and submit them once per month. "If they approve, you can save time and money by not appealing on a case by case basis," Bucknam adds.
• If the reality is that you aren't going to get an E/M and a procedure paid on the same date, make sure you review your reimbursement. Some high level E/M services pay more than some minor procedures. "If you're only going to get paid for one of them, make sure it's the one that pays the most," she says.

Modifier 57 Checklist

• Use for E/M services only.
• Use when an E/M service results in the decision for surgery that day or within the pre-operative global period.
• Make sure the E/M service relates to the surgery.
• Use when the surgery is major, with a 90-day global period.
• Ensure the E/M and surgery occurred on same day or E/M was the previous day.
• Use when the same physician (or ID#) provides the E/M service and performs the surgical procedure.