Urology Coding Alert

The timing plays an important part.

Adding modifiers to your claims can be a simple way to explain your surgeon’s services to a payer and gain appropriate reimbursement – but you need to use them correctly. If the ins and outs of modifier 57 (Decision for surgery) sometimes leave you confused, read on for real-world explanations of when to include it on your claims.

Distinguish From E/M

Modifier 57 applies when the physician performs an E/M service and from the findings of this examination decides that a major procedure is necessary, and the E/M service is distinct from the usual pre-operative work associated with the procedure. Typical examples of major urological procedures include nephrectomy and orchiectomy. 

Watch for ‘Major’ Procedure – and Timing

The number of global days associated with the procedure is another important factor in reporting modifier 57.

“Note that the 57 modifier applies to what Medicare classifies as major surgeries as identified in the Medicare Physician Fee Schedule,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. “That means it has a 90-day postoperative global period.”

Coder Gaye Pratt, RMM, RMC, agrees. “If the procedure performed has a 90 day global period, use the 57 modifier,” she says. “If there is no global period, i.e. a zero day global,   attached to the procedure, use the 25 modifier.”

Important: Modifier 57 only applies when you report the E/M service on the same day as the major procedure or the day before the major procedure. The global period of major procedures include the day before, the day of, and 90 days after the procedure.  

Apply These Examples to Your Practice

For a better understanding of when modifier 57 can be appropriate, consider these real-world examples from urology practices.

Example 1: The urologist saw a patient in the hospital in consultation, and decided that he needed to perform a cystoscopy (52000, Cystourethroscopy [separate procedure]) on the same date as the consultation. Code 52000 carries no global days, so you would modify the visit with 25. The coding could change, however, if the urologist decided that he needed to perform a TURP (52601, Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). This procedure has a 90-day global period. If the TURP is performed that same day or the following day, you would modify the visit with modifier 57 to ensure payment of the E/M service on the same day.

Example 2: During a new patient examination for flank pain and fever, a urologist discovers that the patient has a renal abscess and decides to drain the abscess on the next day. Code 99203 (Office or other outpatient visit for the evaluation and management of a new patient…) with modifier 57 for the new patient visit and the decision for surgery on day one and 50020 (Drainage of perirenal or renal abscess, open) for the drainage the next day.

Resource: To learn more about how to interpret situations for modifier 57, dig into the Medicare Claims Processing Manual, Chapter 12, Section 30.6.6, “Payment for Evaluation and Management Services Provided During Global Period of Surgery,” and Section 40.2, “Billing Requirements for Global Surgeries.”