Otolaryngology Coding Alert

You could improve payment for preparotid and polyp removal service if you know when to append modifier 57.

Hint: To ensure payment for the hospital E/M prior to a same-day decision for surgery, you must use modifier 57 (Decision for surgery). Here are some guidelines to follow with this procedure:

You should only modifier 57 report 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 the date or date before the surgery 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 and Children's University Medical Group Compliance Program.

Example: An otolaryngologist admits a patient with parotitis to the hospital. The otolaryngologist follows the patient, billing follow up hospital visits (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...) each day. Three days later, the patient develops a parotid abscess that requires complex drainage. At that time, the otolaryngologist decides to drain the abscess.

You should append modifier 57 to the hospital care code (9923x) on day 3. 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)." Bottom line: You'll lose the hospital E/M reimbursement without indicating that the surgery was not planned and that the decision for surgery occurred during the E/M prior to the surgical procedure.

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," says Leslie A. Pirkl, CMC, coder at ENT Medical Services in Iowa City, Iowa. 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 Your 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.

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. If a payer has different policies, try to get them writing.

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 the day of the consultation or the day after the consultation.

Example: A family physician requests an otolaryngologist's opinion on a patient's chronic nasal congestion 478.1 (Other diseases of nasal cavity and sinuses). On exam, the ENT notices an intranasal lesion (such as 471.0, Polyp of nasal cavity), which he decides to excise right away. He schedules the patient for excision by internal approach (30117, Excision or destruction [e.g., laser], intranasal lesion; internal approach) the next day.

In this case, you should use modifier 57, says Lynnetta Williams, RHIT, CCS, medical record administrator for VAMC in St. Louis. 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 (30117), Bucknam says.