Urology Coding Alert

When a urologist decides to perform surgery immediately after seeing a patient, he or she can get paid for that initial encounter only by appending a modifier. Whether to use modifier -57 (decision for surgery) or modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) often confuses Urology coders . In general and always for Medicare use modifier -25 on all E/M services associated with minor procedures. Use modifier -57 for an E/M service during which you decide to perform surgery either on the same day or the next day.

By using modifiers -57 or -25, the urologist can be reimbursed for an office visit that is connected in some way to a procedure. Under global surgery rules, if you bill an office visit for a patient on a certain date of service that results in a decision to perform surgery, and that surgery is done within 24 hours of the office visit, you cannot be paid for the office visit. Modifiers -25 and -57 make an exception to those rules, enabling you to receive payment.

Many coders think modifier -25 is for minor procedures, and modifier -57 is for major procedures. But Medicare says to use modifier -25 for procedures with a 0- to 10-day global period, and modifier -57 for procedures with a 90-day global period.

However, CPT does not mention global periods. The 90 days or 0 to 10 days requirements are just for Medicare. A blanket statement such as modifier -57 is only for 90-day globals is misleading if billing a private payer, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a Denver-based billing and coding consultancy. It is a Medicare guideline that limits the use of modifier -57 to procedures with 90-day-or-above global periods, Page says. For CPT coding, all codes in the 10040-69979 range, with the exception of starred procedures, are classified as surgeries. Therefore, technically, modifier -57 could be used for charging an E/M service with any of these codes, Page says. The coder must know how individual payers interpret the -25 and -57 modifiers.

For some private payers, you may have to use modifier -57 for either minor or major procedures. Some private payers still refuse to pay a modifier -25 claim in full. Some of these will pay modifier -57, so you should resubmit the claim with it. However, Medicare restricts the use of modifier -57 to major procedures.

Modifier -57 Scenarios

TURP: A patient comes in on a Monday with prostatism, and the [...]