Otolaryngology Coding Alert

Watch out: Some payers may direct you to use this modifier instead.

In these tough economic times, every dollar counts--and if you're not applying modifier 57 (Decision for surgery) when your ENT performs a hospital E/M prior to the decision for surgery, you could be leaving ethical reimbursement on the table.

Reserve 57 for Major Surgeries

You should only report modifier 57 when the otolaryngologist decides to treat a condition surgically on the day before or the day of a 90-day global period procedure per Medicare guidelines. "The documentation must support that the decision for surgery was made on that date and it was not a scheduled surgery," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

Example: An otolaryngologist admits a patient with parotitis to the hospital for IV antibiotics. Three days later, the patient develops a parotid abscess that requires complex drainage. At that inpatient visit, the otolaryngologist makes the decision to drain the abscess.

You should append modifier 57 to the hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

Modifier 57 tells the insurer that during this E/M the physician decided the patient required surgery, Bucknam says. "If you don't use modifier 57, the insurer will bundle the E/M into the procedure code (42305, Drainage of abscess; parotid, complicated)." You'll lose the hospital E/M reimbursement.

Be careful: In the parotid example, modifier 57 appropriately describes the scenario because 42305 is a major surgery -- one that has a 90-day global period. If the otolaryngologist instead performs a simple drainage (42300, ... parotid, simple), 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), Bucknam says.

Check Payer Policies

Like many modifier rules, modifier 57 guidelines depend on the insurer. Some payers may direct you to use modifier 25 instead of 57, Bucknam says. Insurers usually make this policy because their claims software programs cannot check for an E/M prior to the surgery date. If a payer has different policies, try to get them writing.

Tactic: If the payer does not have them in writing, you can request the email address of the person who gave you the information and then send a confirming email with the content of your call. That way, you have it on the record what you have been told to do in terms of coding, particularly when it goes against AMA coding rules. In this email, you can indicate you understand the instructions from the payer. At the end of the email, ask the person to get back to you if any thing has been misunderstood, so that you can correct what you thought you were told in your call.

Rule: If a payer directs you to use modifier 25 for procedures with a 90-day global period, you must follow the insurer's guidelines, Bucknam says.

Use 57 on Surgery-Resulting Consultations

Depending on payers' rules, you should also use modifier 57 on consultation codes, such as 99241-99245 (Office consultation for a new or established patient ...), if the E/M meets these criteria:

1. the consultation results in the decision to perform a procedure

2. the procedure has a 90-day global period

3. the otolaryngologist performs the surgery within 24 hours of the consultation.

Example: A family physician requests an otolaryngologist's opinion on a patient's recurrent sore throats. The ENT discovers the patient has tonsillitis with +3 tonsils and is having difficulty breathing. So the ENT decides to do surgery the next day.

In this case, you should append modifier 57 to the consultation code (99241-99245) to indicate that the otolaryngologist made the decision for surgery that day. Therefore, the insurer should not bundle the E/M into the surgical code, Bucknam says.