Neurosurgery Coding Alert

Turn to -57 for evaluations with major surgical procedures

If the neurosurgeon provides an E/M service that leads to the decision to perform a surgery with a 90-day global period on the same day, be sure to append modifier -57 to the E/M code. Otherwise, payers could bundle the evaluation into the surgery and deny your practice legitimate compensation. 3 Conditions Govern Your -57 Use To apply modifier -57 (Decision for surgery), the services the surgeon performs must meet three conditions:

1. the E/M service must occur on the same day or the day before the surgical procedure;

2. the E/M service must have directly led to the surgeon's decision to perform surgery; and

3. the surgical procedure following the E/M must have a 90-day global period (that is, it must be a "major surgical procedure"). CPT doesn't have a set time frame for pre- and post-operative services. Medicare, however, directs 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," according to the Medicare Carriers Manual, section 15501.1. Most private (third-party) payers follow similar rules.

Best practice: Always append modifier -57 to the E/M service code, not the surgical procedure code, says Julia A. Appell, CPC, a coder with a general surgical practice in South Bend, Ind.

For example: The surgeon sees a patient with severe headache and nausea, and he quickly determines that the patient has a ruptured aneurysm and schedules immediate surgery (for instance, 61697, Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation).

In this case, you may report both the E/M service (such as a hospital admission, 99223, Initial hospital care, per day, for the evaluation and management of a patient ...) and the intracranial aneurysm surgery because the E/M service resulted in the decision to perform the surgery.

Translation: In other words, the surgery was not previously planned at the time of the evaluation. Start the Global One Day Prior to Procedure The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure itself and includes one preprocedure E/M service for patient evaluation. 

For this reason, payers will normally bundle any E/M service the surgeon provides on the same day as, or the day before, a major procedure to the procedure itself, Appell says.

This means that if the surgeon has already scheduled surgery, and then provides a final E/M service for patient evaluation prior to surgery, you cannot charge separately for the service.

For example: The neurosurgeon schedules diskectomy (for example, 63077, Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], [...]