Part B Insider (Multispecialty) Coding Alert
For Pre-Operative E/M Visit, Intent Determines Your Modifier
Use -57 modifier only if the visit was directly related to the surgery If your surgeon has an evaluation and management visit with a patient within one day of a surgery with a global period, you may need to use a modifier to obtain payment for that visit. But which modifier? If the visit involved the decision to operate on the patient, then you can use the -57 modifier (Decision for surgery). But if the E/M wasn't actually related to the surgery, then you can use the -25 modifier (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The really questionable situations "are a pulmonary embolism or a blood clot in the leg," says Alex. The blood clot could be related to the reason for surgery, or unrelated. Some carriers also require physicians to use the -25 for all preoperative visits, including the decision for surgery, if the procedure has a 10-day global period, notes Grady.
Sometimes, choosing one modifier or the other can be a challenge. The key question to ask is, "would the patient have gotten this if they didn't have the surgery?" says consultant George Alex with Iatro in Baltimore. If the patient had a wound infection or dehiscence, those things "would all be related to the surgery." But if the patient had a myocardial infarction right before surgery, that could be separate. Or if a patient waiting for cardiac bypass surgery developed a fever or urinary tract infection that would be separate.
The most important thing to remember is if you use the -25 modifier for an unrelated condition, you must provide a separate diagnosis, says consultant Robyn Lee with Lee-Brooks Consulting in Chicago. For example, some internal medicine physicians may need to refill a patient's prescription for hypertension medication on the same day that they later provide an unrelated colonoscopy, says consultant Annette Grady with Eide Bailly in Bismarck, ND.
But remember, if an E/M happens the day before a surgery, the -25 modifier won't be available. In that case, just omit the modifier, advises consultant Quinten Buechner with ProActive Consultants in Cumberland, WI.
Part B Insider (Multispecialty) Coding Alert
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