Otolaryngology Coding Alert

Tip: Decision-for-surgery service warrants reimbursement

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

"I'd like to know some better ways to get reimbursed when the otolaryngologist admits a patient and performs a subsequent hospital visit and procedure all in the same day," says Lisa Holder, accounts manager for Dr. Kim E. Schmitt in Birmingham, Ala.

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

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, coordinator of HIM certificate programs at Clarkson College in Omaha, Neb.

Example: An otolaryngologist admits a patient with parotitis to the hospital. 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 (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.

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 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 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.