Get Paid for Preoperative Exams with Modifier -57
Published on Mon Apr 01, 2002
Medicare guidelines stipulate that E/M services provided the day before or the day of a major surgery (a surgery with a 90-day global period) are included in the surgery's global package and are not separately reimbursable. If the preoperative exam prompted the decision for surgery, however, separate reimbursement is warranted and may be achieved if the visit is properly documented and modifier -57 (Decision for surgery) is appended to the appropriate E/M service code.
"Global" Services versus Decision for Surgery
According to Medicare's global surgery rules, payment for surgical procedures includes the surgery itself (the "intraoperative" portion of the service), as well as all postoperative care that does not require a return trip to the operating room for a duration of zero, 10 or 90 days, depending on the procedure. In addition, the global surgical package generally includes all preoperative visits with the patient after the decision for surgery has been made, beginning with the day before surgery for major procedures and the day of surgery for minor procedures (procedures with zero- or 10-day global periods).
For example, a patient previously scheduled to undergo diskectomy (e.g., 63077, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; thoracic, single interspace) meets with the surgeon the day before surgery for a final examination and to discuss last-minute questions and concerns. The E/M visit is included in the global surgical package for 63077 and may not be separately reported.
On occasion, the decision for surgery, which is typically made days or weeks before, may be made the day prior to or even the day of the operation. For instance, the surgeon is called to the emergency department (ED) to examine an automobile accident victim with a closed in head injury. Upon full evaluation, the surgeon admits the patient and immediately operates to evacuate a subdural hematoma (61108, Twist drill hole for subdural or ventricular puncture; for evacuation and/or drainage of subdural hematoma).
In such cases, Medicare will allow separate reimbursement for the preoperative E/M service if certain conditions are met. The Medicare Carriers Manual (MCM), section 15501.1, instructs carriers to "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." The modifier must be appended to the E/M service code, not the surgical procedure code. Modifier -57 need not be appended to E/M services that would normally fall outside the global surgical period (e.g., an E/M visit five days prior to surgery).
Therefore, in the above example of the accident victim with subdural hematoma, the surgeon may report both the surgical procedure [...]
