Pediatric Coding Alert

Reserve modifier 57 for “major” surgeries.

To get the most out of every patient/provider encounter, coders need the ability to identify instances where the provider performs a significant, separately identifiable evaluation and management (E/M) service and a surgical procedure or other type of service on the same date.

If you can be a coder that spots these separate E/Ms, you’ll be invaluable to your practice.

Why?  When the encounter specifics pass muster, you might be able to report an E/M code along with the procedure.

There are rules to follow, however. Once you’ve decided the physician performed a separate E/M, you’ll need to decide whether to append modifier 57 (Decision for surgery) or 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). Your payment for the E/M service might just depend on the correct modifier decision

For all the advice you’ll need on modifiers 25 and 57, check out this expert input.

Use 57 on ‘Major’ Surgeries

You’ll use modifier 57 when the physician performs an E/M service and then decides to perform a “major” surgery during the same encounter, explains Donelle Holle, RN, President of Peds Coding, Inc, and a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind. The surgery can also take place during that day or the next day when it is a major procedure carrying a 90-day global period.

The 57 modifier works just like the 25 modifier, indicating that the pre-procedure E/M is a separate and distinct service and should not be bundled into the global period for the major surgery, Holle continues.

Once the physician decides on surgery, however, the unrelated E/M service ends, says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M. “Under CPT^® rules, after the initial decision to do surgery, related E/M services are then included in the surgical code and would not be billed separately,” she reports. This would apply to E/M visits occurring the day before or the day of the surgery.

No care directly related to the performance of the procedure — such as review of history, informed consent, explaining the procedure to the patient, or informing the patient about the results and follow-up care — can be considered a separate, significant E/M service, Witt says.

Diagnosis coding myth: For claims with modifier 57, Witt says different diagnoses are not required for the E/M service and the separate procedure; but the documentation must clearly support that the E/M represents a separate, significant service.

Pass 90 Before Choosing 57

The global days on the procedure you code will show you if you should use modifier 57 or 25 for separate E/M services. If the procedure code has 0 or 10 global days, the procedure is considered “minor.” “All 90-day [global] procedure codes are major procedures,” Witt relays.