Urology Coding Alert

Question: What are the criteria for using the -57 modifier? We have been using a -57 (decision for surgery) with the evaluation and management (E/M) code whenever the decision for surgery is made. Is it correct to use this code for any surgery that is to be scheduled? Does the surgery have to be scheduled so far in advance or does it have to be the next day to use the -57? A coder from a pharmaceutical company is telling me the only time you use the -57 is if you schedule the next day and if the surgery has a 90-day global.

Missouri Subscriber

Answer: The coder from the pharmaceutical company is correct. Modifier -57 was developed by the American Medical Association (AMA) to identify the E/M visit in which the physician makes the initial decision to perform surgery. Its intent was to indicate to the third-party payer that the service is not part of the global surgical procedure and should be paid separately.

But the pharmaceutical company coder should have qualified his or her statement indicating that Medicare limits the use of modifier -57 to surgeries with a 90-day global period. The modifier is reported on the E/M service if the decision for surgery was made the day before or the day of the surgery. However, if the decision to perform the surgery was made prior to the day before the surgery is scheduled, the service falls outside Medicares global period and does not require modifier -57. This may not necessarily be true of other third-party payers.

Sometimes the decision for surgery is made a week or more in advance of the actual surgery date. Per CPT coding guidelines it would be correct to add the modifier for this visit. However, when modifier -57 is reported payers may deny, as part of global, other office visits between the date of the decision and the date of the surgery, even when these visits are unrelated to the surgery. It is always in the best interest of the practice to check the individual payers guidelines to ensure that claims are submitted correctly.

CPT coding guidelines are not clear on modifier -57. What, exactly, constitutes a surgical procedure? It would appear that the AMA considers all codes in the 10040-69990 range to be surgeries, with the noted exception of starred (*) procedures. Generally, the determination of which codes would require the use of modifier -57 on the E/M service is left up to the individual payer. Normally, payers using the Health Care Financing Administrations (HCFA) RBRVS fee schedule will also adopt Medicare global surgery guidelines.

Medicares global surgery rules require that a single fee be billed and paid for certain services performed by the surgeon before, during and after the procedure. The following items are included in the primary and assistant surgeons fee: (1) Visits with the patient after the decision is made to operate beginning with the day before surgery for major procedures, and the day of surgery for minor procedures; (2) Services that are normally part of the surgery itself; (3) Visits to the patient in the critical care unit; (4) Surgical complications that do not require a return trip to the operating room; (5) 90 days of surgical care for a major procedure. Medicare has two categories of surgical proceduremajor surgery procedures that have a 90-day postoperative period and minor surgical procedures that have a post-op period of zero to 10 days.
The -57 modifier was developed for use with major surgical procedures only. The -25 modifier (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) should be used with minor surgical procedures. The -57 modifier should be used with the appropriate level of E/M to indicate that the decision for surgery was made at that E/M service, and the visit should not be considered part of the global surgical package. As stated, the intent of the modifier is to indicate the visit at which the decision for surgery was made. That may be one day prior to surgery or even the day of surgery, or it might be one week prior to the surgery.