Orthopedic Coding Alert

For elective cases, orthopedists normally make surgical decisions days or weeks before the surgery, but there are occasional patients who require an immediate trip to the operating room.

Medicare allows separate reimbursement for the preoperative E/M service if you meet certain conditions. The Medicare Carriers Manual (MCM), section 15501.1, instructs 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 (Decision for surgery) to indicate that the service was for the decision to perform the procedure."

Always append modifier -57 to the E/M service code, not the surgical procedure code.

Medicare restricts modifier -57 to major surgeries only, and MCM specifically instructs carriers not to pay "for an evaluation and management 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."

If you administer a significant, separately identifiable E/M service on the same date as a minor procedure, including those with zero- or 10-day global periods, 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 the E/M code, instead of modifier -57.