Wiki Decision for Surgery

[az2tn@yahoo.com]

Can someone please tell me if this is considered decision for surgery:


Plan: Dr Smith will evaluate the patient, review her data, and give his recomendations as to possible mediastinscopy versus mediastiontomy, to obtain further lymph nodes to assist with staging of her lung cancer.

Is the initial workup considered the decision making? Seems to me it would be and any other visits inbetween now and the surgery if it happens would be pre-op. Please give me your opinions and any documentation that you may have to support. Thank you so much

 

[Monika Liddle]

Modifier 57 is appended when the decision is made the day prior or day of surgery to an E/M visit.

In your scenario, I would consider his recommendations for surgery as the decision for surgery. I would bill other visits as long it is not the day prior or day of surgery.

 

[OCD_coder]

This appears like a referral to see a surgeon (Dr. Smith). You did not specify if your physician is the surgeon performing the staging procedure or not. I would hesitate to append a modifier 57 if he/she is not the actual surgeon. I don't see anything that talks about scheduling or an actual discussion of the surgery and why to determine if this is the surgeon. Most surgeons discuss risks and recovery instructions when they determine surgery is needed for the patients recovery from the problem.

A modifier 57 is typically the day before or day of surgery, but it does not need to be limited to that. The modifier can be used as tracking for a practice also. For example, I have heard of a plastic surgery practice using the modifier 57 to determine how soon a patient decided to have a procedure done from the consultation.

Source:
CPT Assistant MAY 2009 (AMA and CMS)
If the decision for surgery occurs the day of or day before the major procedure and includes preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H and P) alone). If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H and P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package. Note: Minor procedures have no pre-operative period and the visit on the day of the procedure is generally not payable as a separate service.