Orthopedic Coding Alert

When an orthopedist decides that a patient needs an immediate or near-immediate surgical procedure, coders often question which modifier to append to the office visit code. Modifier 57 (decision for surgery) is used when the patient will have surgery that same day or the next. But some coders prefer modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate the additional decision-making on the part of the physician. Both the date of service and whether the surgery is classified as major or minor determine which modifier to use.

Follow the HCFA Policy

HCFAs policy regarding when to use modifier -57 versus modifier -25 depends largely on the nature of the surgery. Medicare Policy S-99A-Global Surgery states that the initial consultation or evaluation of the problem by the surgeon can be coded separately, using the -57 modifier on the evaluation and management (E/M) code, the day before major surgery or the day of major surgery. For minor or endoscopic procedures on the same day as an E/M visit, the -25 modifier is used to identify a service that is above and beyond care normally associated with the procedure.

Use Modifier -57 for Major Surgery Only

Gina Hagerman, an office manager for an orthopedic surgeon in Columbus, Ohio, explains that in her practice the physician often evaluates new patients, and then has them return for caudal injections. We typically will have a new patient for whom the physician schedules an injection (62311). The injection takes place in our office, usually within two weeks of the initial visit, Hagerman says. It has been suggested to Hagerman that she can use the -57 modifier with 99204 (office or other outpatient visit for the evaluation and management of a new patient ...) because 62311 is considered surgery, and it was at the initial visit that the physician decided to schedule the injection, but thus far she has not attempted to code this way.

The question here is the correct use of modifier -57. Major surgeries have 90-day global periods, the preoperative portion of which begins one day prior to surgery. The use of modifier -57 keeps an E/M service from being bundled within that global surgical period. It is applied when a physician sees a patient (at an E/M office visit or emergency department consult, for example) and decides that immediately, later that day, or the following day, the patient needs surgery. The modifier essentially says to the payer: I didnt know the patient would need surgery until I examined him or her in the initial E/M visit, so the E/M portion is a separately billable item. Modifier -57 would be appended to the E/M code reported on the day of or the day before major surgery when the E/M service resulted in the decision to perform surgery. Therefore, in Hagermans case, the -57 modifier for a surgery or injection scheduled weeks later is not necessary, because the time lag between the initial E/M visit and the scheduled injection removes any concern about the initial E/M being bundled.

When to Use Modifier -57 In Office

Although use of the -57 modifier for office-based procedures is unusual, it is not unheard of. Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., offers an example. If an orthopedic practice has the capacity to reduce fractures in the office, then the -57 is a possibility, Callaway says. For instance, if an established patient reports with an injured wrist, and the orthopedist diagnoses a displaced distal radius fracture that needs to be reduced, 99214-57 (office or other outpatient visit for the evaluation and management of an established patient) can be reported with 25605 (closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, with or without fracture of ulnar styloid; with manipulation) if the physician reduced the fracture at that encounter.

The practice can also bill for any x-rays taken in office and for casting supplies if the private insurer or local Part B carrier reimburses for them. This varies from state to state and carrier to carrier.

Modifier -25 Is the Same-day Option for Injections

When a patient complains of joint pain, the orthopedist will complete the history and examination and may often determine that the patient needs an injection or series of injections. But rather than postpone the first injection for a later date, the first injection is performed during the same visit. In these circumstances, modifier -57 cannot be used in combination with the E/M code and the injection code because the injection is a minor surgical procedure, and -57 is reserved for major surgeries.

Rather, modifier -25 can be used to indicate that the E/M visit was a significant, separately identifiable service by the same physician on the same day of the procedure or other service. In this case, the other service is the injection. If the patient is scheduled for a series of injections, E/M visits cannot be charged during the subsequent visits. With subsequent injections after the initial E/M visit and injection, only the injection and the drug supply codes can be charged.