Otolaryngology Coding Alert

Another modifier may grace your claim when describing principal physician service. Find out what.

Contrary to popular thinking, modifier 57 does not apply exclusively for consultation codes only. Medicare may have stopped paying for consult codes, but this doesn't mean you have to stop using modifier 57. Here are 2 tips on how you can use this modifier to suit your practice's needs.

Background: Starting January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) eliminated consult codes from the Medicare fee schedule.

Non-Consult Inpatient Codes Keep Modifier 57 Alive

With CMS eliminated consult codes (99241-99245, 99251-99255) for Medicare patients, you might have wondered if modifier 57 (Decision for surgery) would remain useful. The answer? You can still use this modifier for a non-consult inpatient E/M code, so long as your documentation supports it.

This is because any major procedure includes E/M services the day before and the day of the procedure in the global period, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. "The only way you can be paid properly for an E/M performed the day before the major surgery or the day of the surgery is to indicate that it was a decision for surgery (modifier 57), which also indicates to the payer that the major procedure was not a pre-scheduled service," she explains.

Past: Say the otolaryngologist carries out a level three inpatient consult in which she figures out the patient requires complex drainage for his parotid abscess the day after the consult. The physician decides to drain the abscess the next day. Appending modifier 57 to the E/M code (99253, Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity.) would show payers why you're billing the consult in addition to the major surgery performed the next day (42305, Drainage of abscess; parotid, complicated).

Present: Using the same scenario for a Medicare patient, the physician would not code a consult but instead would bill an initial hospital visit for the service performed when they initially evaluate the parotid abscess. Based on meeting the requirements for a 99253, the service would convert to a 99221 (Initial hospital care, per day, for the evaluationand management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity.) for a Medicare patient where a consult is not an acceptable code. You would add modifier 57 to 99221 on the day the physician decided to perform 42305. In this case, you shouldn't bill any E/M services on the second day since the decision for surgery was made the day before.

More than one physician can use an initial hospital care code for the same patient. If two physicians from different specialties are both consulting on a patient, both physicians will use the initial code, but the physician of record will use the initial code with modifier AI (Principal physician of record). Say the otolaryngologist is the principal physician --" the one servingthe patient's care and admitting the patient -- don't forget to append modifier AI, in addition to modifier 57.

Consequence: If you don't use modifier 57, the payerwill bundle the E/M into the procedure code (42305 in our example), and you'll lose the hospital E/M reimbursement.

What if: On the other hand, what if the otolaryngologist saw the patient the day before the parotid drainage (42305)when she had not yet determined to do the drainage? Then she decided to perform the parotid drainage on the second day when she performed her E/M. In this case, you would bill the E/M (subsequent hospital visits 99231-99233) withmodifier 57 along with 42305 on the second day. But what should you bill on the first day since that day is considered within the major surgery global period? Since the physician had not made the decision for surgery at that point in time, it would be inappropriate to use modifier 57 for that E/M service, says Cobuzzi.

Dilemma: If you billed the E/M the day before the major surgery without modifier 57, you would likely get a denial, yet you should not bill it with this modifier because modifier 57 is only used for the next day's E/M service (the day of the decision for surgery).

Solution: "The only possible option available to the practice is to submit the E/M the day before the surgery with no modifier since no decision for surgery was made, and then appeal the denial when it is received. There is no guarantee that it will be paid, but that is the best possible route for the practice," remarks Cobuzzi.

Tell Between Modifiers 25, 57

You should only report modifier 57 if the physician decides to treat a condition surgically on the day of, or the day before a procedure with a 90-day global period. Take note, too, that the E/M service should result in the initial decision to perform the surgery, affirms Teena Pfyffer, CPC, back office director, Rocky Mountain ENT in Missoula, MT. "You may make the decision to perform surgery for a patient with an emergent condition that requires immediate surgery," she adds.

Don't bill an E/M code with modifier 57 if the physician provided the service on the day before, or the day of the procedure with a 0 or 10-day global period. Say the otolaryngologist performs a simple drainage (42300, ... parotid, simple) instead of 42305. In this case, you should use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) with the E/M.

Do this: Using modifier 25 would call for documentation supporting that the E/M service was above and beyond the reason for the visit.

What about pre-op visits? Modifier 57 would only be used if the E/M is a result of a decision to perform a surgery that is unrelated to the post op global. Any other E/M that your physician performs in the global is inclusive to the post op global. Therefore, modifier 57 is not appropriate in this case. Pre-op visit means the physician has already made the decision for surgery, and you may not use modifier 57 to be paid for a pre-op visit. CPT® includes this service in the global package, so never bill it with a modifier 57.