Medicare Compliance & Reimbursement

Keep E/M documentation apart to demonstrate the service's 'separate' status To report an E/M service that prompts a follow-up procedure, you must append either modifier 25 or modifier 57 to the appropriate E/M service code. Which modifier you select, however, depends not only on the nature of the E/M service but also on the length of the global period associated with the follow-up procedure. Here are the facts you'll need to make the choice easy. Extra motivation: The Office of Inspector General (OIG) has targeted "services within the global period" -- including E/M services with modifiers 25 or 57 -- for special investigation as part of its 2008 Work Plan. Call on 57 for 'Major' Follow-up Procedures You should append modifier 57 (Decision for surgery) to an E/M service that occurs on the same day, or on the day before, a major surgical procedure, and which results in the physician's decision to perform the surgery, instructs Raemarie Jimenez, CPC, director of exam content for the AAPC. CMS guidelines identify a major surgical procedure as any procedure with a 90-day global period. Note that the global period for a major surgical procedure begins one day prior to the procedure itself. Direct from the source: Medicare's Internet Only Manual, section 40.2, tells carriers, "Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier 57 to indicate that the service was for the decision to perform the procedure." Example 1: A surgeon receives a request to evaluate a patient for acute right-upper quadrant pain and tenderness. Following a full evaluation, the surgeon decides to remove the gallbladder and schedules an immediate cholecystectomy (47562, Laparoscopy, surgical; cholecystectomy). In this case, the surgeon may claim both the surgical procedure (47562) and the examination that led to the decision to perform the surgery (for example, 99243, Office consultation for a new or established patient ...). Because the cholecystectomy is a major procedure, you should append modifier 57 to 99243. The available documentation should specifically note that the E/M service resulted in the decision for surgery. Use modifier 57 when the claim meets all of the following criteria: 1. The E/M occurs on the same day of or the day before the surgical procedure. 2. The E/M service directly prompted the surgeon's decision to perform surgery. 3. The surgical procedure following the E/M has a 90-day global period. 4. The same surgeon (or another surgeon with the same tax ID) provided the E/M service and the surgical procedure. Example 2: The surgeon schedules cholecystectomy (47562) for a patient with a diseased gall bladder. On the day prior to surgery, [...]