Dermatology Coding Alert

Published on Mon Jan 16, 2006 PDF

Assign 57, not 25, for E/M prior to a major surgical procedure

Modifiers 24, 25 and 57 all have one special talent -- allowing you to code an E/M service on the same day as (or during the global period of) a procedure. But they are not interchangeable -- to avoid denials for the E/M service, you need a foolproof method for choosing between modifiers 24, 25 and 57.

Ask yourself these questions to decide which modifier will provide the carrier with an accurate picture of the E/M service.

Question 1: Does the E/M Follow Another Service?

When an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the appropriate E/M code.

By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the E/M service is not included in the global surgical package of the previous procedure, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Remember: You cannot bill separately for E/M related services during the global period, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. Routine postoperative care during the global period is included in the global surgical package.

Example: The dermatologist performs 17106 (Destruction of cutaneous vascular proliferative lesions [e.g., laser technique]; less than 10 sq cm) on a patient's left arm. Within the 90-day postoperative period, the patient complains of a rash on his right leg. The dermatologist performs an evaluation for this new, distinct problem (that is, the rash on the right leg is unrelated to surgery on the left arm). In this case, append modifier 24 to the office visit during which the dermatologist assesses the right leg.

Modifier 24: Conditions for Use

When you report modifier 24, the E/M service must meet these criteria:

• The E/M service occurs during the postoperative period of another procedure.
• The current E/M service is unrelated to the previous procedure.
• The same physician (or tax ID) who performed the previous procedure provides the E/M.

Note: This is true even if the two physicians have different specialties or sub-specialties, says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif. If a dermatologist who performs lesion excisions refers the patient to a Mohs specialist in the same group for the evaluation of further lesions, modifier 24 is still necessary. Medicare does not make a distinction between subspecialties or use of diagnosis codes.

Question 2: 'Major' or 'Minor' Procedure?

When the surgeon decides to perform another procedure during an E/M service and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately.
 
Depending on the length of the procedure's global period, you should append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) to the appropriate E/M code.
 
Modifier 25: Conditions for Use

When appending modifier 25, make sure the E/M service meets these requirements:

• The E/M is significant and separately identifiable from any "inherent" E/M component included with other services or procedures you report on the same day.

• The E/M may be related or unrelated to other procedures or services you report on the same day.

• The service/procedure the surgeon provides on the same day as the E/M service should have a zero-day,  10-day or "XXX" global period.

• The same physician bills the E/M and other procedures or services on the same day.

Minor procedures mean 25: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with zero-day, 10-day or "XXX" global periods, you should append modifier 25 to the E/M code, says Linda Parks, MA, CPC, CCP, coding specialist in Marietta, Ga.

90-Day Global = Modifier 57

When the surgeon decides to perform major surgery (that is, a surgery with a 90-day global period) and provides the surgery that day or the next day, you should append modifier 57 to the E/M code.
 
For example, if the dermatologist evaluates a patient for a potential skin graft (15260, Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids and/or lips; 20 sq cm or less) on Monday, and then plans the skin graft for the same day or the following day, you should append modifier 57 to the E/M code.

You can find Medicare guidelines for modifier 57 outlined in the Medicare Carriers Manual (section 15501.1).

Modifier 57: Conditions for Use

To append modifier 57 properly, you must remember these points:

• The E/M service occurs the day of or the day before a major surgical procedure (a procedure with a 90-day global period).

• The E/M service must prompt the surgical procedure that follows.

• The E/M service must be related to the procedure that follows.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package for the skin graft, leading to a loss in reimbursement.