Pediatric Coding Alert

Question: When a pediatrician refers a patient for surgery, can I use modifier 57?

Georgia Subscriber Answer: No. The doctor who refers a patient for surgery does not use modifier 57 (Decision for surgery). Instead, the physician who bills for the procedure may use modifier 57 on the E/M code.

Why: A procedure's global package includes a preoperative visit, which the physician usually provides the day of or the day prior to the operation. The decision for the surgery had already been made at another visit. Therefore, the surgery's global package doesn't bundle the visit during which the physician made the decision to do the surgery. When the physician makes the decision for surgery on the same day that he performs the procedure, you must use modifier 57 on the E/M code to prevent the payer from mistakenly bundling the visit into the procedure's global package.

Referral example: A pediatrician refers a patient with recurrent otitis media (such as 381.10, Chronic serous otitis media, simple or unspecified) to an otolaryngologist for possible ventilating tubes. The ENT evaluates the patient and decides the patient's condition justifies same-day surgery (such as 69436, Tympanostomy [requiring insertion of ventilating tube], general anesthesia). To indicate the office visit should not be lumped into the tympanostomy code's 90-day global period, the ENT coder appends modifier 57 to the E/M code.

Check with payers before using modifier 57. Some insurers restrict the modifier to use with major surgeries -- those containing 90-day global periods, such as treatment of clavicle fracture (23500, Closed treatment of clavicular fracture; without manipulation). Other payers may not follow the CMS guidelines and allow the modifier on any procedure regardless of the global period.

For instance, a pediatrician might use modifier 57 on an office visit code in which she decided to perform a procedure, such as subluxation treatment (24640, Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation), says the American Academy of Pediatrics. Conversely, you could use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the E/M service is significant and separately identifiable from the procedure.