Pulmonology Coding Alert

Take a hint from a CPT®'s global period when choosing between modifiers 25 or 57.

Contrary to popular thinking, modifier 57 does not apply exclusively for consultation codes only. Medicare may have stopped paying for consult codes, but this doesn't mean you have to stop using modifier 57. Here are two tips on how you can use this modifier to suit your practice's needs.

Background: Starting January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) eliminated consult codes from the Medicare fee schedule.

Non-Consult Inpatient Codes Keep Modifier 57 Alive

With CMS eliminated consult codes (99241-99245, 99251- 99255) for Medicare patients, you might have wondered if modifier 57 (Decision for surgery) would remain useful. The answer? You can still use this modifier for a non-consult inpatient E/M code, so long as your documentation supports it.

This is because any major procedure includes E/M services the day before and the day of the procedure in the global period, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. "The only way you can be paid properly for an E/M performed the day before the major surgery or the day of the surgery is to indicate that it was a decision for surgery (modifier 57), which also indicates to the payer that the major procedure was not a pre-scheduled service," she explains.

Past: Say the pulmonologist carries out a level four inpatient consult in which she figures out the patient requires thoracoscopy with pleurodesis for his recurring, persistent pleural effusion (511.9). The physician decides to perform thoracoscopy with pleurodesis the day after the consult. In this case, appending modifier 57 to the E/M code (99254, Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity...) would show payers why you're billing the consult in addition to the major surgery performed the next day (32650, Thoracoscopy, surgical; with pleurodesis [e.g., mechanical or chemical]).

Note: Largely, modifier 57 only comes in handy to a pulmonology practice that includes thoracic surgeons, or to a pulmonologist who is expanding her practice to provide more extensive surgical procedures. Otherwise, no standard  pulmonology procedure carries a 90-day global period, in which case, appending modifier 57 may not be appropriate.

Present: Using the same scenario for a Medicare patient, the physician would not code a consult, but instead would bill an initial hospital visit for the service performed when they initially evaluate the pleural effusion. Based on meeting the requirements for a 99254, the service would convert to a 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 that is of moderate complexity...) for a Medicare patient where a consult is not an acceptable code. You would add modifier 57 to 99222 on the day the physician decided to perform 32650. In this case, you shouldn't bill any E/M services on the day of surgery since the decision for surgery was made the day before, and the remaining visits are included in the surgical global package.

Always be wary of the consequence. If you don't use modifier 57, the payer will bundle the E/M into the procedure code (32650 in our example), and you'll lose the hospital E/M reimbursement.

On the other hand, what if the pulmonologist saw the patient the day before the thoracoscopy with pleurodesis (32650) when she had not yet determined to do this procedure? Then she decided to perform 32650 on the second day after performing her E/M. In this case, you would bill the E/M (subsequent hospital visits 99231-99233) with modifier 57 along with 32650 on the second day.

But what should you bill on the first day since that day is considered within the major surgery global period? Since the physician had not made the decision for surgery at that point in time, it would be inappropriate to use modifier 57 for that E/M service, says Cobuzzi.

Dilemma: If you billed the E/M the day before the major surgery without modifier 57, you would likely get a denial, yet you should not bill it with this modifier because modifier 57 is only used for the next day's E/M service (the day of the decision for surgery).

Solution: "The only possible option available is to submit the E/ M the day before the surgery with no modifier since no decision for surgery was made, and then appeal the denial when it is received. There is no guarantee that it will be paid, but that is the best possible route for the practice," remarks Cobuzzi.

Tell Between Modifiers 25, 57

You should only report modifier 57 if the physician decides to treat a condition surgically on the day of, or the day before a procedure with a 90-day global period. Take note, too, that the E/M service should result in the initial decision to perform the surgery, affirms Teena Pfyffer, CPC, back office director, Rocky Mountain ENT in Missoula, MT. "You may make the decision to perform surgery for a patient with an emergent condition that requires immediate surgery," she adds.

Don't bill an E/M code with modifier 57 if the physician provided the service on the day before, or the day of the procedure with a 0 or 10-day global period. Say the pulmonologist performs thoracentesis (32421, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) instead of 32650 on the same day of the E/M. Append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to an E/M that is performed on the same day as a 0- or 10-day global period procedure. No modifier would be required of the E/M took place the day before the procedure.

Do this: Using modifier 25 would call for documentation supporting that the E/M service was above and beyond the reason for the visit.

What about pre-op visits? Modifier 57 would only be used if the E/M is a result of a decision to perform a major surgical procedure. Any other E/M that your physician performs in the global is inclusive to the post op global. Therefore, modifier 57 is only appropriate for pre-op visits that meet the requirement of "decision for surgery".