Podiatry Coding & Billing Alert

Remember: Codes with a 90-day global period are considered major surgeries.

Modifiers carry a significant amount of weight on your claims. If you forget to append the appropriate modifierwhen needed, Medicare could reduce or even deny the claim.

Answer the following questions about modifier 57 (Decision for surgery), an option for your evaluation and management (E/M) services and protect your full reimbursement today.

Only Append Modifier 57 When Surgery is Major

Question 1: Can we append modifier 57 if the procedure following the E/M service is minor?

Answer 1: No. You should use modifier 57 only when the surgery is major, never minor.

"The 57 modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery," according to the Medicare Claims Processing Manual 40.2.

Definition: Codes with a 90-day global period are considered major surgeries, according to the Medicare Physician Fee Schedule (MPFS).

Don't forget: "Remember that while we normally think of it [modifier 57] being usedprior to the original surgery, it also applies to any decision to do follow-up surgery during the 90-day global period of the original surgery unless that surgery was to be performed in stages," says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

Never Mix Up Modifiers 25 and 57

Question 2: Can we ever use modifiers 25 and 57 interchangeably?

Answer 2: No. You should never confuse modifier 57 with 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).

You should append modifier 57 only when the surgery is major, which means it has a 90-day global surgery period.

"If the patient is having major surgery, which is a surgery that has a 90-day global surgical period, and the physician performs an E/M on the day before or day of the surgery, then use the 57 modifier," says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

On the other hand, you should only append modifier 25 to indicate a distinct E/M with a minor procedure (zero or 10-day global period) performed on the same day.

Tip: Suzan Hauptman, CPC, CEMC, CEDC, AAPC Fellow, senior principal of Ace Med Group in Pittsburgh, gives a helpful way to remembering this rule by knowing it is a larger number than the modifier 25, thus it is used for major procedures as opposed to minor ones.

"A/B MACs (B) 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," according to the Medicare Claims Processing Manual 30.6.6.

Communicate With Your Payers

Question 3: Can you offer a tip on how to improve modifier 57 use?

Answer 3: You should always check with your payers on their policies regarding modifier 57, according to Witt. She shares examples of such policies below:

Witt points out that according to Palmetto GBA, you should not submit modifier 57 with E/M codes that are clearly for new patients like 92002, 92004, 99201-99205, 99324-99328, 99281-99285, 99321-99323 and 99341-99345. Since these codes are new patient codes, they are automatically excluded from the global surgery package. So, they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed. These codes are also automatically excluded from the global surgery package.

When a surgeon is seeing a post-operative patient, Novitas and WPS state that if an E/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another unrelated procedure, you must bill the E/M service with both modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) and modifier 57.

Consider This Modifier 57 Scenario

Take a look at the following scenario to see modifier 57 in action: After having an accident with a lawnmower, an established patient goes to the podiatrist's office thinking he only has a laceration on his right great toe. After evaluation, the podiatrist schedules a toe amputation (28820, Amputation, toe; metatarsophalangeal joint) to be performed the following day.

What to do:  You can claim the surgical procedure (28820) and the examination (99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: ...) because the podiatrist didn't plan the amputation prior to the evaluation. Usemodifier 57 (Decision for surgery) when the E/M service directly led to the podiatrist's decision to perform surgery.

Remember: Always append modifier 57 to the E/M service code, not the surgical procedure codes. If you append modifier 57 to procedure codes, you can expect claims denials.

Solution: Report 28820 and 99213-57. You can append modifier 57 to the E/M code because the amputation is considered a major procedure.