Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 20, 2005 PDF

Clear up confusion about what situations require 57 and 25

Medicare provides specific instructions on how to append modifiers 57 and 25. If you're not sure which is appropriate for certain podiatry services, check out the scenarios below to get your feet firmly planted on correct coding ground.

Scenario #1: After having an accident with a lawnmower, an established patient goes to the podiatrist's office thinking he only has a laceration on his right great toe. After evaluation, the doctor schedules a toe amputation (28820, Amputation, toe; metatarsophalangeal joint) to be performed the following day.

What to do: You can claim the surgical procedure (28820) and the examination (99213) because the podiatrist didn't plan the amputation prior to the evaluation. Use modifier 57 (Decision for surgery) when the E/M service directly led to the podiatrist's decision to perform surgery.

Remember: Always append modifier 57 to the E/M service code, not the surgical procedure codes, says Julia A. Appell, CPC, a coder with a general surgical practice in South Bend, IN. If you append modifier 57 to procedure codes, you can expect claims denials.

Solution: Report 28820 and 99243-57. You can append modifier 57 to the E/M code because the amputation is considered a major procedure.

Scenario #2: A podiatrist sees a new patient for a consult (99243 ) for a growth on the third right toe. He performs a full history, exam and decides to perform a biopsy (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure] unless otherwise listed; single lesion).

What to do: Report the E/M service and the biopsy because the biopsy isn't a major procedure. Append modifier 25 (Significant, separately identifiable evaluation and management service...) when the service is separately identifiable from the same-day procedure and is assigned a global period of less than 90 days. Modifier 25 tells the payor that the E/M service goes beyond the included history and physical to a much more significant level.

Try this: Separate notes for the procedure and the E/M aren't required, but can help you avoid denials, according to Laureen Jandroep, OTR, CPC, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, NJ.

Solution: Report 11100 and 99243-25. Because the biopsy isn't a major surgical procedure and has a zero-day global period, append modifier 25 instead of modifier 57.