Urology Coding Alert

One detail can point you to 57 instead of 25.

Every coder knows that appending modifiers can sometimes make or break a claim, depending on how savvy you are. That's because modifiers help you explain circumstances in a particular case and why your coding for the encounter might be different from expected. Appending the correct modifier and including thorough supporting documentation can give a clear picture of your provider's services and boost your bottom line (when appropriate). Reporting modifiers incorrectly, however, can lead to denials, downshifts in reimbursement, and more.

One of the trickiest modifiers for coders to master can be 57 (Decision for surgery). Read on for top tips from coding experts that will help you file cleaner claims every time.

Tip 1: Look for 'Major,' Not 'Minor'

You should use modifier 57 only when the surgery is major, never minor.

Explanation: "The 57 modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery," according to the Medicare Claims Processing Manual 40.2.

"Note that the 57 modifier applies to what Medicare classifies as major surgeries as identified in the Medicare Physician Fee Schedule," says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. "That means it has a 90-day postoperative global period."

Key point:  All codes with a 90-day global period represent services that are considered major surgeries, according to the Medicare Physician Fee Schedule.

Important: Modifier 57 only applies when you report the E/M service on the same day as the major procedure or the day before the major procedure. The global period of major procedures includes the day before, the day of, and 90 days after the procedure.

"Remember that while we normally think of modifier 57 being used prior to the original surgery, it also applies to any decision to do follow-up surgery during the 90-day global period of the original surgery unless that surgery was to be performed in stages," explains Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, NM.

Tip 2: Don't Switch 57 for 25

You should never confuse modifier 57 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

As previously mentioned, you should append modifier 57 only when the surgery is major, which means it has a 90-day global surgery period.

"If the patient is having major surgery, which is a surgery that has a 90-day global surgical period, and the physician performs an E/M on the day before or day of the surgery, then use modifier 57," says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

Modifier 25 comes into play when you are faced with the same circumstances with a minor procedure (zero or 10-day global period) performed on the same day.

Tip: Suzan Hauptman, CPC, CEMC, CEDC, AAPC Fellow, senior principal of Ace Med Group in Pittsburgh, PA, gives a helpful way to remembering this code by knowing it is a larger number than the modifier 25, thus it is used for major procedures as opposed to minor ones.

"A/B MACs (B) may not pay for an evaluation and management service billed with the CPT^®  modifier 57 if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period," according to the Medicare Claims Processing Manual 30.6.6.

Brink reiterates that if the patient has a minor surgical procedure, which carries a l0-day global surgical period, you should not use modifier 57 when the physician performs an E/M on day of the minor procedure.

Tip 3: Always End With a Decision for Surgery

The CPT^® manual specifically states you should use modifier 57 when an E/M service results in the initial decision to perform the surgery.

Important: The E/M service must occur on the same day of or the day before the surgical procedure.

Using modifier 57 lets the provider receive credit for the additional work required to make the decision to do major surgery on the day of or day before that surgery, Witt says.

Caution: You should never report modifier 57 for an E/M service the day of or day before a preplanned or scheduled major (90-day) surgical procedure.

"If the decision to do surgery is made before this time period, no modifier 57 is reported for the E/M service as all major procedures include preoperative clearance the day of or the day before surgery," Witt says.

Tip 4: Follow Examples for Confident Coding

For a better understanding of when modifier 57 can be appropriate, consider these real-world examples from urology practices.

Example 1: The urologist saw a patient in the hospital in consultation, and decided that he needed to perform a cystoscopy (52000, Cystourethroscopy [separate procedure]) on the same date as the consultation. Code 52000 carries no global days, so you would modify the visit with 25. The coding could change, however, if the urologist decided that he needed to perform a TURP (52601, Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]). This procedure has a 90-day global period. If the TURP is performed that same day or the following day, you would modify the visit with modifier 57 to ensure payment of the E/M service on the same day.

Example 2: During a new patient examination for flank pain and fever, a urologist discovers that the patient has a renal abscess and decides to drain the abscess on the next day. Code 99203 (Office or other outpatient visit for the evaluation and management of a new patient...) with modifier 57 for the new patient visit and the decision for surgery on day one and 50020 (Drainage of perirenal or renal abscess, open) for the drainage the next day.