Part B Insider (Multispecialty) Coding Alert

Published on Fri Jun 04, 2004 PDF

Follow these guidelines to get paid for -57 modifier

Surgeons are throwing away reimbursement for evaluation and management services, where they see a patient on a consultation and decide to perform surgery immediately. They can bill for those visits using the -57 modifier (decision to perform surgery) but seldom do so, according to consultant Robyn Lee with Lee-Brooks Consulting in Chicago.

This frequently happens in the hospital setting, according to Lee. "They won't bill for the consult because they don't realize they can, and it's all documented in the medical record," she says.

But billing for an E/M visit based on the decision to perform surgery requires proper documentation, say experts. For one thing, the surgeon's chart must show clearly that the decision for surgery only happened in that pre-operative visit.

The chart should include a physician recommendation or plan that spells out the reasons why surgery is necessary. And it should spell out that the surgeon explained "the benefits and risks of surgery to the patient and all the things he was supposed to do," says Georgeann Edford with Coding Compliance Solutions in Birmingham, MI.

Alot of discussion must happen in that visit if the surgeon is choosing to perform surgery soon afterwards, according to consultant Annette Grady with Eide Bailly in Bismarck, ND. The surgeon must find out about anything in the patient's past history that could cause changes in anesthesia or placement of hardware such as stents or orthopedics. "You have to have a complete understanding of the patient," says Grady. "There's a lot of risk involved, whether it's an arthroscopic surgery or a major orthopedic surgery."

You're more likely to see the -57 modifier used in emergency circumstances, notes consultant George Alex with Iatro in Baltimore. If there's no reason for surgery to happen right after the decision to operate, then surgeons will generally wait a couple of weeks. This allows time for the patient to have preoperative blood work, fast before receiving anesthesia or control some underlying illness.

For payors to pay for the -57 modifier, "they have to see why it was medically necessary to do this the day of or the day before," says Alex. The reason can't simply be that the patient's going on vacation and wants to get the surgery out of the way. "In order to do that kind of surgery, the physician is exposing themselves to additional risk because they didn't go through the procedures" to prepare the patient, adds Alex. So there has to be some urgent reason for rushing ahead.

Lee gives the example of a patient who comes to a surgeon for a consult on an angioplasty and the patient's suffering extreme bleeding. "It's a decision to do surgery immediately because you're afraid the patient's going to have a major cardiac event."