Podiatry Coding & Billing Alert

Never append modifiers 55 and 56 to E/M codes.

With four surgical modifiers to choose from, it's easy to get stumped when multiple DPMs take part in a global surgery package. If you overlook a modifier, however, you could end up short on reimbursement -- or, more likely, the subject of an audit for overpayment! Avoid surgical modifier missteps with this rundown.

Check off 57 for Visits Prompting Surgery

Don't miss out on deserved payments by neglecting modifier 57 (Decision for surgery).

Medicare says: The surgeon's initial consultation or evaluation of the problem to determine the need for surgery is a separately payable service not bundled into the CPT surgical code, states the Medicare Claims Processing Manual, Chapter 12, Section 40.1 (www.cms.gov/manuals/downloads/clm104c12.pdf).

Note that this policy applies only to major surgical procedures (which typically have a 90-day global); the initial evaluation is always included in the allowance for a minor surgical procedure, the Medicare manual states.

Avoid confusion: The difference between a "decision for surgery" encounter and a preoperative visit is the pre-op visit occurs "after the decision is made to operate beginning with the day before the day of surgery for major procedures [with 90-day globals] and the day of surgery for minor procedures," explains the Medicare manual.

Careful: Do not append modifier 57 to the surgical CPT code. Rather, report 57 with the E/M code that best represents the decision for surgery encounter. Do not append modifier 25 when the encounter results in a decision for surgery.

Example: A DPM evaluates a patient with a fractured ankle to determine whether it needs surgical repair. The patient has complications due to other health problems; thus, the DPM provides a level-two inpatient E/M service. To ensure the DPM receives reimbursement for the E/M service (which would otherwise be bundled with the surgical CPT code reported on the same day), make sure to add modifier 57 to 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a  comprehensive history; a comprehensive examination; and medical decision making of moderate complexity ...).

Stop: Do not report 57 in conjunction with a preplanned or prescheduled surgery.

Choose 56 over E/M Code for Pre-Op Only

If one podiatrist performs the pre-op exam only while another DPM (same or different practice) handles the procedure, you should not report the pre-op visit with an E/M code.

What to do: Report the pre-op encounter with the surgical CPT code and a 56 modifier (Preoperative management only), says Becky Zellmer, CPC, MBS, CBCS, operations supervisor for Madison, Wis.- based SVA Healthcare Services. Verify the CPT code and procedure fee with the operating surgeon to include on your claim. Do not append modifier 56 to non-surgical procedure codes, such as E/M codes.

Example: A patient with a fractured medial malleolus presents for a pre-op exam. The operating DPM is occupied with another patient, so another podiatrist on call completes the pre-op service. Under this pre-op provider's National Provider Identifier (NPI), report 27766 (Open treatment of medial malleolus fracture, includes internal fixation when performed) and append modifier 56 to reflect pre-operative care only.

Reimbursement: Reporting modifier 56 will generally earn the DPM providing pre-op care a portion of the global surgical fee for the CPT code you are reporting. For instance, BlueCrossBlueShield of Mississippi's policies indicate 15 percent payment on modifier 56 (www.bcbsms.com/assets/docs/Modifier_Usage_Guide.pdf). Other payers may not reimburse for pre-op care, such as Oxford Health, which assigns no value to modifier 56 (www.oxhp.com/secure/policy/mod_54_55_56_107.html).

Match 54 with Surgical Management Only

You're asking for an audit if you forget modifier 54 (Surgical management only) when other DPMs are providing pre- or post-op care.

Append modifier 54 to the surgical CPT code to represent the surgical work, which is generally reimbursed at 70 percent of the procedure fee, although this amount may vary by payer. In the case of a medial malleolus fracture, your claim sheet should read 27766-54 when the service is limited to the operation. Connect Postoperative Care with 55

Don't try to bypass the global package by billing for post-op visits after surgery. "The post-op visits are included within the surgical follow-up time frame [usually 90 days for a major procedure]," notes Renee Hilgert, owner and manager of Podiatry Claims, a consulting service in Dallas.

If your DPM provides postoperative management only after another physician performs a surgical procedure, report modifier 55 (Postoperative management only) appended to the surgical code. Many payers follow Medicare's lead in assigning 15 percent of the global package fee for postoperative care, but check with your specific payer to confirm the amount.

No E/M code: As with pre-op care, postoperative visits related to the surgery are included in the surgical procedure code, so don't bill an office visit (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) during the global period for care related to the surgery.

Double up: In some cases, you may append both modifiers 54 and 55 to the same surgical CPT code. Example: If DPM #1 performs the pre-op exam while DPM #2 performs the surgical fracture repair and the follow-up work, DPM #1 would report 27766-56 for the pre-op portion and DPM #2 would report 27766-54-55 for the surgery and post-op care, Zellmer indicates.

That way, the payer knows exactly how the care broke down and each DPM earns his or her deserved allotment.