Ob-Gyn Coding Alert

Here’s how this modifier is different from modifier 25.

Appending modifiers to your CPT^® codes is an easy way to portray your ob-gyn’s services– but you have to use them correctly. If you’re scratching your head when it comes to modifier 57 (Decision for surgery, then check out these real-world explanations of when to include it on your claims.

Distinguish From E/M

Modifier 57 applies when the physician performs an E/M service and from the findings of this examination decides that a major procedure is necessary, and the E/M service is distinct from the usual pre-operative work associated with the procedure. Typical examples of major gynecologic and obstetric procedures include hysterectomy based on severe uncontrolled hemorrhage, surgical treatment for an incomplete abortion, or a colpotomy for drainage of a pelvic abscess.

Watch for ‘Major’ Procedure – and Timing

The number of global days associated with the procedure is another important factor in reporting modifier 57.

“Note that the 57 modifier applies to what Medicare classifies as major surgeries as identified in the Medicare Physician Fee Schedule,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. “That means it has a 90-day postoperative global period.”

Coder Gaye Pratt, RMM, RMC, agrees. “If the procedure performed has a 90 day global period, use the 57 modifier,” she says. “If there is no global period or only a 10-day global period attached to the procedure, use the modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service).”

Important: Modifier 57 only applies when you report the E/M service on the same day as the major procedure or the day before the major procedure. The global period of major procedures include the day before, the day of, and 90 days after the procedure.  

Apply These Examples to Your Practice

For a better understanding of when modifier 57 can be appropriate, consider these real-world examples from ob-gyn practices.

Example 1: A 17-year-old patient comes into the ED after an elective abortion elsewhere. Your ob-gyn has never seen her before. Your ob-gyn performs a D&C and admits the patient for intravenous antibiotic therapy. Which modifier should you use?

Answer: You should use modifier 57. -Since the treatment of the incomplete abortion (59812, Treatment of incomplete abortion, any trimester, completed surgically) carries a 90-day global period, you should use modifier 57 on the E/M service.

As for the E/M code, you have several options depending what the ED physician does. If the ED physician doesn’t report the ED visit (99281-99285), you can. If the ED physician does report the ED visit, you should fall back on a new outpatient visit code (99201-99205). If the ED physician requested a consult from your ob-gyn, you should report an outpatient consult code (99241-99245). For any of these coding choices, append modifier 57 to the E/M service to show that the ob-gyn decided to perform surgery during this visit.

Bonus info: You should count all subsequent care as part of the postoperative care following the surgical treatment of the incomplete abortion. Also, if your ob-gyn admits the patient to the hospital that day for the surgery, you should roll all services he performed into the admission code, to which you’ll append modifier 57. The exception to this rule would be if your ob-gyn documented a consultation. In that case, when the ob-gyn subsequently admits the patient, you should report an inpatient consultation code for that encounter with modifier 57.

Example 2: The ob-gyn sees a patient with vaginal bleeding. During the exam, the ob-gyn identifies polyps in the cervical os and decides to remove the polyps the same day instead of asking the patient to return. Which modifier should you use?

Answer: You should use modifier 25. You should report the visit code (9921x) with modifier 25 appended in addition to 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]). Appropriately appending modifier 25 means that your practice will receive separate payment for an E/M service that the ob-gyn performed on the same day as a procedure or other service. But keep in mind the physician must have documented that he addressed the signs, symptoms, or condition before deciding to perform the procedure and that his work was above and beyond normal pre/post procedure work. In fact, Medicare has stated that the decision to do a same day minor procedure is included in the payment for that procedure (Chapter I, General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, Revision Date: January 1, 2016, pages 17-18).

Resource: To learn more about how to interpret situations for modifier 57, dig into the Medicare Claims Processing Manual, Chapter 12, Section 30.6.6, “Payment for Evaluation and Management Services Provided During Global Period of Surgery,” and Section 40.2, “Billing Requirements for Global Surgeries” (URL: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf).