Otolaryngology Coding Alert

Question: My ENT wants to append modifier 57 on an E/M to decide to schedule sinus surgery. How is this modifier used and is it payable? For and E/M that resulted in 31231, could I append modifier 57 to 99213?

Oklahoma Subscriber

Answer: You-ll append modifier 25 to 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) because that code has zero global days.

Use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if the procedure being done is a minor procedure -- that is, it has zero to 10 global days per the Medicare Fee Database, and you are saying that the E/M is more than the small E/M associated with a minor procedure. Rather, it is a significant, separately identifiable E/M. That significant, separately identifiable E/M may ultimately be the decision to perform the minor procedure.

Use modifier 57 (Decision for surgery) for a major global-period procedure -- that is, a code that has a 90-day global period (per Medicare's fee schedule, column U) that was not scheduled before your ENT performed the E/M. Modifier 57 tells the payer that the E/M is for a service before an unplanned procedure. During that E/M, the physician decided to perform the procedure and the patient is inside the major procedures global period (day of or day before).

How it works: 90-day global period procedures include the day of the procedure and the day before the procedure, so if your physician does an E/M and decides to do a procedure that you had not already scheduled and planned for (the day of the procedure or the day before) without using a modifier, you will not normally be paid. Without the 57 modifier on the E/M, the insurer will not pay for the E/M, but include it as part of the major procedure's global period.

Let's say one of your patients comes into the ER with tonsils so swollen they are blocking his airway. He had been under conservative treatment and wasn't scheduled for a tonsillectomy. The airway is blocked, and your ENT cannot wait to perform surgery. You will code the E/M service in the ER where your ENT decides to take the patient to the OR, and you-ll append modifier 57 to indicate it was a decision for surgery.