Making the Most of Modifiers:
Obtain Payment for Same-day E/M and Procedure
Published on Sat Jun 01, 2002
Most procedures (those with zero-, 10- or 90-day global periods, as well as diagnostic tests with XXX global days) listed in the CPT manual include some E/M services, such as pre- and postoperative evaluation, that should not be billed separately. Nonetheless, an E/M service often may be reported separately.
To report a procedure and an E/M service that are provided on the same day, you should append the appropriate E/M code with 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 -57 (Decision for surgery). Note: These modifiers always are appended to the E/M codes, not procedure codes. Because these modifiers are used to override an edit and obtain additional reimbursement, they are subject to abuse by providers and carriers, and claims involving either modifier are monitored closely, particularly if a pattern of overuse has been observed.
To appropriately append modifier -25 or -57, you must answer the following questions: Was the E/M service significant and separately identifiable? Did the E/M service result in the decision to perform the procedure? Was the E/M service provided for an unrelated problem?
Modifying E/M Services With Major Procedures For major surgeries (those with 90-day global periods), the issue is fairly straightforward, says Randa Blackwell, coding specialist with the department of otolaryn-gology at the University of Maryland in Baltimore. "If the otolaryngologist sees a patient and, as a result of that visit, surgery is performed that day or the next, the visit may be reported separately with modifier -57 appended," she says. Although many of the procedures with 90-day global periods performed by otolaryngologists are prescheduled, or elective, this is not always the case, Blackwell notes. For example, the otolaryngologist may admit a patient with parotitis to the hospital. Three days later, the patient develops a parotid abscess that requires draining. At that time, the otolaryngologist makes a decision for surgery (to drain the abscess) and indicates it by appending modifier -57 to the hospital care code, which is reported in addition to the surgery. "This lets the carrier's computer know that although the hospital visit being reported is part of the procedure's global period, it may be billed separately because the decision for the surgery was made during that encounter," Blackwell says, adding that this applies to visits performed the day before surgery with a 90-day global period as well.
"That's why it's very important to append modifier -57 to the E/M service. Otherwise, the carrier has no way of knowing that the surgery was not preplanned but, rather, resulted from the examination," she points out. "This is particularly important for inpatient consultations, which result in next-day surgery. [...]
