Part B Insider (Multispecialty) Coding Alert

Published on Thu Mar 10, 2005 PDF

Reserve modifier -25 for evaluations with minor surgical procedures

If you're not appending modifier -57 to evaluation and management services (E/M) that lead your surgeon to perform major surgery with a 90-day global period the day of or the day before surgery, you could be cheating your practice out of valuable compensation. Without this modifier attached, carriers can bundle the E/M services into the surgical procedure and deny the surgeon his rightfully earned E/M fee.

Meet These 3 Conditions Before You Use Modifier -57

To apply modifier -57 (Decision for surgery), the services the surgeon performs must meet four conditions:

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

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

3.  The surgery must not have been scheduled prior to the day of that E/M; and

4.  The surgical procedure following the E/M must have a 90-day global period (that is, it must be a "major surgical procedure"). CPT's definition of global period states it includes "one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical [H&P])."

CPT doesn't have a set time frame for pre- and postoperative 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.

Only 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, IN.

For example: The surgeon receives a request to evaluate a patient for acute right-upper quadrant pain and tenderness. Following a full evaluation, the surgeon decides to remove the gallbladder and schedules a laparoscopic cholecystectomy (47562, Laparoscopy, surgical; cholecystectomy) for the next day.

In this case, the surgeon may claim both the surgical procedure (47562) and the examination that led to the decision to perform the surgery (for example, 99243, Office consultation for a new or established patient ...). Because the cholecystectomy is a major procedure, you should append modifier -57 to 99243. The documentation should also specifically note that the E/M service resulted in the decision for surgery.

Translation: In other words, the surgeon did not plan the cholecystectomy prior to the time of the evaluation, and therefore you may report the evaluation separately because the service led to the decision to perform surgery.

No -57 If Surgery Prescheduled

The global surgical period for major surgeries under the Medicare fee and the CPT global package schedule begins one day prior to the procedure and includes one preprocedure E/M service for patient evaluation (H&P).

Therefore, payers will 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 prior to surgery, you cannot charge separately for the service.

For example: The surgeon schedules cholecystectomy (47562) for a patient with a diseased gallbladder. On the day prior to surgery, the surgeon meets with the patient for a final evaluation, to answer any questions the patient has and to provide additional instructions for recovery.

In this case, you cannot charge separately for the E/M service. Because the surgeon already decided to perform surgery at a previous encounter - and because the E/M service occurs within the global period of the surgery - you should bundle this final presurgery E/M into the cholecystectomy.

Don't try to "cheat": Merely scheduling pre-op services two  or more days before surgery  will not necessarily make the services payable.

Insurers may consider such services to be "screening" exams unless there is some specific medical indication.

Avoid Confusing -57 With -25

For same-day E/M services with procedures assigned a global period of less than 90 days, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), rather than modifier -57, to the E/M service code, says Susan Callaway, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C. Medicare restricts modifier -57 to major surgeries only. And the MCM specifically instructs carriers not to pay "for an evaluation and management service billed with the CPT modifier -57 if it was provided on or the day before a procedure with a zero- or 10-day global surgical period (minor surgeries)."

For example: The surgeon sees a new patient in consultation (99243) for a breast mass. After performing a full history and exam, the surgeon decides to perform a needle core biopsy (19100, Biopsy of breast, percutaneous, needle core, not using imaging guidance [separate procedure]).

In this case, you may report both the E/M service and the aspiration. But because the aspiration is not a major surgical procedure (the procedure has a zero-day, rather than a 90-day, global period), you should append modifier -25 - not modifier -57 - to 99243. Therefore, you should report 19100, 99243-25.

Unsure? Check the Fee Schedule Database for Global Periods

If you aren't sure of a procedure's global period (and therefore whether you should append modifier -25 or -57 to an E/M procedure provided at the same time as the surgery), consult the Medicare Physician Fee Schedule database.

The database is available as a free download from the CMS Web site and contains useful information on all current CPT codes, including RVUs, tips on proper modifier use and, of course, global period information.

To download the Physician Fee Schedule Database, visit www.cms.hhs.gov/physicians/pfs/. Scroll down until you find the link labeled "2005 National Physician Fee Schedule Relative Value File." Click on the link and follow the instructions to download the database.