Primary Care Coding Alert

Question: I noticed modifier 57 in CPT Appendix A. As a family physician, I have rarely used this modifier. Should I use it more often?

North Dakota Subscriber

Answer: Modifier 57 (Decision for surgery) doesn't usually apply to FP situations. When a physician performs an E/M in which he makes the decision for same-day surgery, you append modifier 57 to the E/M code (such as 99311-99313, Subsequent nursing facility care, per day, for the evaluation and management of a new or established patient ...).
 
Many insurers follow Medicare's policy and expect modifier 57 only on claims containing major surgeries. So if an FP performs only minor surgeries - those containing less than 90-day global periods - you wouldn't have a reason to use modifier 57.
 
In fact, Medicare's list of the top-50 FP-performed codes contains only one procedure that has more than zero global days. But even 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion) is ineligible for modifier 57 because the code has a 10-day, not a 90-day, global period.

 - Answers to You Be the Coder and Reader Questions provided by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Shrewsbury, N.J.; Victoria S. Jackson, CEO of OMNI Management Inc. in southern California; Jeffrey Linzer Sr., MD, MICP, FAAP, representative to the ICD-9-CM editorial advisory board; Maggie Mac, CMM, CPC, CMSCS, consulting manager at Pershing, Yoakley & Associates in Florida; and Rudy Tacoronti, MD, director of occupational medicine for DeKalb Health Systems in Decatur, Ga.