Orthopedic Coding Alert

Modifiers 25 and 57 are two E/M modifiers that often cause confusion for coders. To understand when to properly use these modifiers, you should first understand a few coding concepts.

According to CPT, the surgical package always includes the following services in addition to the operation:

- local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

- subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical)

- immediate postoperative care, including dictating operative notes and talking with the family and other physicians

- writing orders

- evaluating the patient in the postanesthesia recovery area

- typical postoperative follow-up care.

A minor procedure is a procedure that bundles zero or 10 global days of postoperative care into its surgical package, according to Medicare. And a major procedure is a procedure that bundles 90 global days of postoperative care into its surgical package, according to Medicare.

CPT's definition of the surgical package is only part of the story. The Medicare Physician Fee Schedule (PFS) contains a lot of important information regarding payment for all CPT codes, including the Global Surgery Indicator. This indicator provides time frames that apply to each surgical procedure. Here's how the PFS breaks down the indicators:

- 0 days (000) -- Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; E/M services on the day of the procedure are generally not payable.

- 10 days (010) -- Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period are included in the fee schedule amount; E/M services on the day of the procedure and during the 10-day postoperative period are generally not payable.

- 90 days (090) -- Major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule amount.

- Maternity (MMM) -- Maternity codes; usual global period does not apply.

- N/A (XXX) -- The global concept does not apply to the code.

- Carrier (YYY) -- The carrier determines whether the global concept applies and establishes postoperative period, if appropriate, at time of pricing.

- Other (ZZZ) -- The code is related to another service and is always included in the global period of the other service.

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) to E/M codes only, and never to the surgery code. The CPT manual gives the following description for using modifier 25:

CMS further instructs that you should append modifier 25 to E/M codes for services performed on the same date as minor procedures only, according to the Internet Only Manual (IOM) section 30.6.6, Chapter 12, (available at www.cms.hhs.gov/Manuals/IOM/list.asp). Basically, if your provider performs an E/M service on the same day as a minor procedure and it is significant and separately identifiable from the E/M bundled into the minor procedure's surgical package, you can bill an E/M service, append the modifier 25 to it and receive separate reimbursement.

Now, let's look at some examples:

Example 1: Patient presents for a follow-up of her osteoporosis. During the visit, she also complains of a recent color-changing mole. The provider decides to biopsy the mole at the visit (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) after taking a history on the mole and performing an examination of the area. The provider also refills the patient's Fosamax and orders some labs to check on her liver function. In this scenario, the provider would bill out an E/M service and append modifier 25 with the osteoporosis diagnosis (for example, 733.01, Senile osteoporosis), as well as the biopsy.

Example 2: Patient presents to the provider's office for a scheduled joint injection into the knee. The provider takes a short updated history, checks the knee and reconfirms the prior discussion regarding the injection. The provider then performs the injection and tells the patient to return as needed. In this scenario, you should bill only the injection (20610, Arthrocentesis, aspiration and/or injection major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). This carries zero global days according to the PFS, so you should consider it a minor procedure. The E/M service that the provider performed would be considered the bundled E/M the day of or the day before the procedure as described in the surgical package. Note: If the office purchased the medication used, you would also bill for it in the above scenario.

Like modifier 25, you should append modifier 57 (Decision for surgery) to E/M codes only, and never to the surgery code. The CPT manual gives the following description for using modifier 57: "An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service."

CMS further instructs that you should append modifier 57 to E/M services performed on the day of or day before a major procedure only. The agency also states that it will not pay for an E/M service with modifier 57 if it was provided on the day of or the day before a procedure with a zero- or 10-day global surgical period, according to the IOM section 30.6.6, Chapter 12. Look at the following example for clarification.

Example 1: Patient presents to the emergency department (ED). The ED physician thinks the patient may have a tibial fracture and calls in an orthopedic surgeon. The orthopedist comes to see the patient, orders some labs and an x-ray. The results come back and a diagnosis of a tibial fracture is confirmed. The surgeon decides that the patient needs to be taken to surgery for an open reduction internal fixation (ORIF). The OR is called and the patient is prepped and taken to surgery that day by the same surgeon. The E/M service performed by the orthopedic surgeon should be submitted with the modifier 57 as an ORIF carries 90 global days in the surgical package.

Without attaching a modifier, there is no way that a payer can tell that the E/M service being submitted is not the E/M service included in the surgical package. Finally, remember, don't concentrate on where the physician performed the service. Instead, rely on what type of service (minor versus major) your orthopedist performed with the E/M service to drive your modifier selection.

-- Betty A. Johnson, CPC, CCS-P, CIC, CCP, is the president and principal consultant of CPC Solutions Inc., with more than 20 years experience in the field. She is an American Academy of Professional Coders (AAPC) professional medical coding curriculum instructor, has spoken nationally for providers, payers and institutions including Blue Cross Blue Shield, the AAPC and The Coding Institute. Betty holds a B.A. in Health Care Administration.