Otolaryngology Coding Alert

Tip: Decision-for-surgery service warrants reimbursement You could improve payment for preparotid and polyp removal service if you know when to append modifier -57.

"I'd like to know some better ways to get reimbursed when the otolaryngologist admits a patient and performs a subsequent hospital visit and procedure all in the same day," says Lisa Holder, accounts manager for Dr. Kim E. Schmitt in Birmingham, Ala.

To ensure payment for the hospital E/M prior to the decision for surgery, you must use modifier -57 (Decision for surgery). Here are some guidelines to follow with this procedure: Reserve -57 for Major Surgeries You should only report modifier -57 when the otolaryngologist decides to treat a condition surgically on the day before or the day of a 90-day global period procedure per Medicare guidelines. "The documentation must support that the decision for surgery was made on that date and it was not a scheduled surgery," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, coordinator of HIM certificate programs at Clarkson College in Omaha, Neb.

Example: An otolaryngologist admits a patient with parotitis to the hospital. Three days later, the patient develops a parotid abscess that requires complex drainage. At that time, the otolaryngologist decides to drain the abscess.

You should append modifier -57 to the hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...). Modifier -57 tells the insurer that during this E/M the physician decided the patient required surgery, Bucknam says. "If you don't use modifier -57, the insurer will bundle the E/M into the procedure code (42305, Drainage of abscess; parotid, complicated)." You'll lose the hospital E/M reimbursement.

Be careful: In the parotid example, modifier -57 appropriately describes the scenario because 42305 is a major surgery - one that has a 90-day global period. If the otolaryngologist instead performs a simple drainage (42300, ... parotid, simple), you should use modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), Bucknam says.

Check Payer Policies Like many modifier rules, modifier -57 guidelines depend on the insurer. Some payers may direct you to use modifier -25 instead of -57, Bucknam says. Insurers usually make this policy because their claims software programs cannot check for an E/M prior to the surgery date. If a payer has different policies, try to get them writing.

Rule: If a payer directs you to use modifier -25 for procedures with a 90-day global period, you must follow the insurer's guidelines, Bucknam says. Use -57 on Surgery-Resulting Consultations Depending on [...]