Practice Management Alert

Medicare carriers "pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure," according to the Medicare Carriers Manual (MCM). Most third-party payers follow similar rules.

Best practice: Always append modifier -57 to the E/M service code, not the surgical procedure code, says Julia A. Appell, CPC, a coder with a general surgical practice in South Bend, Ind.

Question: When does a global surgical period technically begin for billing purposes?

Answer: The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure itself and includes one preprocedure E/M service for patient evaluation. Therefore, payers will bundle any E/M service the physician provides on the same day as, or the day before, a major procedure.

This means that if a surgeon has already scheduled surgery, and then provides a final E/M service prior to surgery, you cannot charge separately for the service.

Example: Suppose one of your surgeons schedules cholecystectomy (47562) for a patient with a diseased gall bladder. On the day prior to surgery, the surgeon meets with the patient for a final evaluation, to answer any questions the patient has and to provide additional instructions for recovery.

In this case, you cannot charge separately for the E/M service. Because the surgeon already decided to perform surgery at a previous encounter - and because the E/M service occurs within the global period of the surgery - you should bundle this final presurgery E/M service into the cholecystectomy code.

Don't try to "cheat": Merely scheduling pre-op services two or more days before surgery will not necessarily make the service payable. Insurers may consider such services to be "screening" exams unless there is some specific medical problem, such as hypertension or diabetes, that necessitated a separate E/M service.

Question: When is modifier -25 appropriate for same-day E/M services with procedure codes that have a global period?

Answer: For same-day E/M services with procedures assigned a global period of fewer than 90 days, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), rather than modifier -57, to the E/M service code, says Susan Callaway, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C.
 
Medicare restricts modifier -57 to major surgeries only. In addition, the MCM specifically instructs carriers not to pay "for an evaluation and management service billed with the CPT modifier -57 if it was provided on or the day before a procedure with a zero- or 10-day global surgical period."

Question: How can I check the global period on a procedure code if I'm not sure what it is?

Answer: If you don't know the global surgical period for a procedure (and therefore whether you should append -25 or -57 to an E/M procedure provided at the same time as the surgery), consult the Medicare Physician Fee Schedule database.

The database is available as a free download from the CMS Web site and contains useful information on all current CPT codes, including relative value units (RVUs), tips on proper modifier use and global period information.

To download the Physician Fee Schedule database, visit www.cms.hhs.gov/physicians/pfs/. Scroll down until you find the link labeled "2005 National Physician Fee Schedule Relative Value File." Click on the link and follow the instructions to download the database.