Urology Coding Alert

Question: We use modifier -57 on separately identifiable E/M services during which the decision for surgery is made, either on the day before or the day of a surgical procedure. We make sure the service warrants a separate charge, but we still get denied for the claims. Do you have any clue what we are doing wrong?

California Subscriber

Answer: If you're appending modifier -57 (Decision for surgery) on minor surgical services, that's probably why you're seeing denials for these charges. Modifier -57 is used for separately identifiable E/M services rendered the day before or day of a major surgical package. Modifier -57 tells the payer, "We know that this preoperative visit is part of the surgical package, but the physician needed a separate, identifiable E/M in order to reach the decision to perform surgery." Usually services requiring that type of E/M have 90-day global packages. Minor services often do not require that type of E/M service from a physician.

If your physician does a consultation the day before or on the day of surgery, and the physician decides that the patient needs major surgery at that time, you should put modifier -57 on your consultation codes. Remember that some carriers do not recognize modifier -57 and will never pay for an E/M service, even one during which the decision for surgery was made. These carriers include all of this work as part of their surgical package. Appeals with documentation as well as copies from the CPT book have helped in a few instances in obtaining reimbursement for this preoperative decision-making. Always consider an appeal when you know you are right.

Answers to You Be the Coder and Reader Questions contributed by

Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 19-urologist practice in Indianapolis.