Wiki Modifier 57 and Elective surgery

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Vstruzinski

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Hello,

Can you use a modifier 57 on an E/M for an elective surgery? The surgery does have a 90 global and the E/M is completed the day before surgery. I found the information below on Supercoder.com

Question: We attached modifier -57 to an E/M service that resulted in a decision to remove a lesion. Our Medicare carrier rejected our claim. What did we do wrong?

Virginia Subscriber
Answer: You should attach modifier -57 (Decision for surgery) when an E/M service, such as 99214 (Office or other outpatient visit ... established patient ...), results in a decision for major surgery during the patient preoperative period. The preoperative period on a major surgery includes the day of and the day prior to the procedure. Typically, your internist should order an emergency procedure or surgery, not a scheduled or elective surgery.

Thank you,
 
I think this is a great question. Ordinarily I would say yes, but then I kept referring to the elective part and have to think it would be included in the surgical package. Looking forward to other coder responses.
 
Lesion removal is MINOR surgery

The problem is that excision of a skin lesion is MINOR surgery (global days 0-10)

F Tessa Bartels, CPC, CEMC
 
Good afternoon,

The surgery I posted is not what I code for it was and example of were I found that you can not use 57 on elective surgeries. I work in orthopedic spine and our surgeries are considered elective. Would we be able to use the 57? Just because it is an elective surgery the patient must still go through a clearance prorocess



Answer: You should attach modifier -57 (Decision for surgery) when an E/M service, such as 99214 (Office or other outpatient visit ... established patient ...), results in a decision for major surgery during the patient preoperative period. The preoperative period on a major surgery includes the day of and the day prior to the procedure. Typically, your internist should order an emergency procedure or surgery, not a scheduled or elective surgery.
 
I always bill 57 with 90 days global procedure when an E/M is the one where the decision for surgery is made. I billed for Ortho and now doing the same for Derm.

Vstruzinski said:
Good afternoon,

The surgery I posted is not what I code for it was and example of were I found that you can not use 57 on elective surgeries. I work in orthopedic spine and our surgeries are considered elective. Would we be able to use the 57? Just because it is an elective surgery the patient must still go through a clearance prorocess



Answer: You should attach modifier -57 (Decision for surgery) when an E/M service, such as 99214 (Office or other outpatient visit ... established patient ...), results in a decision for major surgery during the patient preoperative period. The preoperative period on a major surgery includes the day of and the day prior to the procedure. Typically, your internist should order an emergency procedure or surgery, not a scheduled or elective surgery.
Click to expand...
 
This is a great question to bring to the forum. Nowhere could I find in the CPT, NCCI Manual on the CMS Surgical Guidelines, nor the Global Surgical Fact sheet is there a criteria limiting the use of modifier 57 when a surgical procedure is "elective". I only found it on the Risk Table in the E&M (95') Documentation Guidelines.

Coders need to be very careful about including the encounter where the workup and decision for surgery takes place and bundling it into the "global" package. Neither the CPT nor CMS global package bundles the initial encounter where the provider evaluates the condition and initiates the treatment plan/makes the decision for a major surgery regardless if it is elective or emergent.

A minor procedure has a brief E&M bundled into the procedure (0-10 day global) - mod 25
A major procedure has a preop service bundled into the procedure (90 day global) -mod 57

http://www.cms.gov/Outreach-and-Edu...oducts/downloads/GloballSurgery-ICN907166.pdf

PREOP VISITS – Guidelines **
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.
 
Elective surgery is surgery that is scheduled in advance.
Per CPT assistant May 2009, '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&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.'
So in case of elective surgery the decision was made well in advance and if the patient comes for H&P the day before the surgery (Pre operative clearance), the visit is not separately billable as it is included in the surgical package.

Hope that helps

Brightwin
 
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