Otolaryngology Coding Alert

Identify all the key components for proper use of modifier 57.

Sometimes, a physician may make a determination to perform an unplanned surgical procedure after examining a patient during an evaluation and management (E/M) visit. While most coders within any surgical specialty will occasionally encounter these situations, they are often guilty of making a few fundamental mistakes during the coding process.

If a provider makes the decision for surgery during an E/M visit for the day of or the day after the E/M encounter, you should always know to append modifier 57 (Decision for surgery) to the E/M code if the surgical procedure is considered major. This modifier explains to the insurance company that the decision for surgery was made the day of or the day prior to the surgical procedure.

Understanding the circumstances in which you should append modifier 57 can often mean the difference between a payment and a denial. Read further for all you need to know about the modifier 57 coding process.

Know What's Included in Global Surgical Package

According to Medicare, the following services (preceding surgery) are included in the global surgical package:

• "Preoperative visits after the decision is made to operate. For major procedures, this includes preoperative visits the day before the day of surgery. For minor procedures, this includes preoperative visits the day of surgery."

On the same note, the following services are not included in the global surgical payment, but you can override them using modifier 57:

• "Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier 57. This visit may be billed separately only for major surgical procedures."

Determine Major versus Minor Surgical Procedure

While Medicare pays for the use of modifier 57 the day of or the day before a major surgical procedure, the same cannot be said for minor surgical procedures. According to Medicare:

• "The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier 25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure."

As you can see, the difference between a major and minor surgical procedure will determine what modifier you apply in certain situations. If the provider performs an E/M visit on the same day of a minor surgical procedure, you will apply modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service. If the provider makes the decision to perform a major surgical procedure during an E/M visit on the day before or the same day as the procedure, you will apply modifier 57 to the E/M service.

However, making a determination on what defines a major-versus-minor surgical procedure is not clear-cut. In order to determine what qualifies as a major-versus-minor surgery, you need to examine the surgery's global period. Accord to Medicare:

• "Carriers pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT^® modifier 57 to indicate that the service resulted in the decision to perform the procedure. Carriers may not pay for an evaluation and management service billed with the CPT^® modifier 57 if it was provided on the day of or the day before a procedure with a 0- or 10-day global surgical period."

In other words, if the surgery in question has a global period of 90 days, you may consider it a "major" surgery. If the surgery has a global period of 10 days or 0 days, you should classify it as a "minor" surgery and therefore not apply modifier 57 if the provider makes the decision for surgery.

Remember 2 More Factors on 57 Decision

Now that you have a firm grasp on how to differentiate minor-versus-major procedures, you will want to make sure you have a complete understanding of how you should bill E/M visits preceding a minor surgical procedure. "Remember that according to Medicare, and contrary to CPT^®, the E/M visit immediately prior to the minor procedure is considered 'routine preoperative service' and would not meet the definition of 'significant, separate service' under Medicare guidelines," relays Jennifer M. Connell, CPC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, owner of E2E Health Solutions in Victoria, Texas. This is because minor procedures contain a very small E/M component, which is considered the "routine preoperative service" by definition. "In this case, a different diagnosis is usually needed to bill an E/M visit on the same day as a minor procedure to Medicare," Connell explains.

However, you will also want to consider Medicare's rules surrounding different diagnoses as stated in its Global Surgery Booklet: "Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient's medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim."

Lastly, if the provider opts to perform surgery following an E/M visit, you may occasionally have to monitor the date of the surgery to determine whether or not modifier 57 is applicable. If the surgeon does not perform the surgery within a day's time following the decision for surgery, you should not bill out a modifier 57 with the E/M visit. Therefore, it may make sense to hold off on billing out for the E/M visit until the provider schedules an exact date and time for the surgery.

"Modifier 57 is often incorrectly used with the date of service when a provider makes the decision for a surgery scheduled days or weeks from that date of service," states Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, vice president at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. "Modifier 57 should only be used to 'break the global period' established by major surgeries so that the provider can be paid," Cobuzzi explains.

An example of modifier 57 usage would be for a patient who arrives to the emergency department (ED) with such bad tonsillitis that the hypertrophied tonsils are closing the airway. The otolaryngologist cannot opt for conservative measures and must operate that day. After an evaluation, the patient is brought into the operating room (OR) for a tonsillectomy in order to open the airway. The ED E/M visit would be billed with a 57 because the tonsillectomy code, 42826 (Tonsillectomy, primary or secondary; age 12 or over), has a 90-day global period.