Otolaryngology Coding Alert

Assign 57, not 25, for E/M prior to major surgical procedure

Your surgeon performs an E/M service on the same date as a procedure, so you reach for modifier 25, right? Not so fast. Ask yourself two questions first.

Question 1: Does the E/M Follow Another Service?

When an E/M service occurs during a postoperative global period, but for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated E/M service by the same physician during a postoperative period) to the appropriate E/M code.

By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the payer should not include the E/M in the global surgical package of the previous procedure, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Modifier 24: Conditions for Use

When you report modifier 24, the E/M service must meet these criteria:

- The E/M service occurs during the postoperative period of another procedure. 

- The current E/M service is unrelated to the previous procedure.

- The same physician (or tax ID) who performed the previous procedure provides the E/M.

Remember: You cannot bill separately for related services during the global period. All payers include routine postoperative care during the global period in the global surgical package.

Example: A patient undergoes laryngectomy (31365, Laryngectomy; total, with radical neck dissection) for cancer of the larynx (161.9, Primary malignant neoplasm of the larynx [not elsewhere classified]). Laryngectomy is a major procedure, with a 90-day global period.

Several weeks later, the patient returns to the ENT with a new problem (for instance, 388.70, Otalgia, unspecified; earache NOS). The physician performs an evaluation for this new, distinct problem. In this case, you should append modifier 24 to the correct E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with a diagnosis of 388.70.

Learn more: For additional information on modifier 24, see -Call on 24 for Complication Evaluations--Maybe- later in this issue.

Question 2: -Major- or -Minor- Procedure?

When the surgeon decides to perform a procedure during an E/M service and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately. Depending on the length of the global period associated with the procedure, you should append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) to the appropriate E/M code.

Minor procedures mean 25: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with 0-day, 10-day or -XXX- global periods, you should append modifier 25 to the E/M code, says Linda Parks, MA, CPC, CCP, a coding specialist in Marietta, Ga.
Example: The ENT sees a new patient on consult from a primary-care physician. The patient is complaining of recurrent cough and dysphasia, as well as a -lump in the throat." (ENTs will sometimes describe this condition as globus, 784.9, Other symptoms involving head and neck.  Do not confuse this with globus hystericus, 300.11, which is a psychiatric disorder.)

Modifier 25: Conditions for Use

When appending modifier 25, the E/M service must meet these requirements:

- The E/M is significant and separately identifiable from any -inherent- E/M component included with other services/procedures you report on the same day.

- The E/M may be related or unrelated to other procedures/services you report on the same day.

- The service/procedure the surgeon provides on the same day as the E/M service should have a 0-day, 10-day or -XXX- global period.

- The same physician bills the E/M and other procedures/services on the same day.

After conducting a history and exam, the ENT decides to conduct a laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic). The exam reveals a mass in the larynx (for example, 784.2, Swelling, mass or lump in head and neck). He records these findings in a separate note.

In this case, because documentation supports billing for a separate E/M service, you may report both the E/M service (for example, 99244, Office consultation for a new or established patient ...) and the laryngoscopy (31575). Because 31575 includes a 0-day global period, you should append modifier 25--rather than modifier 57--to the E/M code.

Keep reading: Look for complete information on modifier 25 in an upcoming edition of Otolaryngology Coding Alert.

90-Day Global = Modifier 57

When the surgeon decides to perform major surgery (that is, a surgery with a 90-day global period that has not already been scheduled) and provides the surgery that day or the next day, you should append modifier 57 to the E/M code, according to Medicare guidelines outlined in the Medicare Carriers Manual (section 15501.1).

Example: Two days after an otolaryngologist admits a patient with parotitis to the hospital, the patient develops a parotid abscess that requires complicated draining.
In this case, you should report both the parotid drainage (42305, Drainage of abscess; parotid, complicated) and the appropriate-level hospital visit (for example, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...). The parotid drainage's 90-day global procedure includes a preoperative E/M service. Therefore, you should append modifier 57 to 99232 to indicate that this E/M service led to the decision for surgery.

Modifier 57: Conditions for Use

To append modifier 57 properly, you must remember these points:

- The E/M service occurs the day of or the day before a major surgical procedure (a procedure with a 90-day global period).

- The E/M service must prompt the surgical procedure that follows.

- The E/M service must be related to the procedure that follows.

- The same physician (or tax ID) provides the E/M service and the surgical procedure.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M into the global surgical package for 42305, leading to a loss in deserved reimbursement.