57 modifier - decision for surgery

willette

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If a patient comes in on 1-01-2012 for a visit and decision for surgery is made but surgery is not scheduled till 2-15-2012 is it necessary to add a modifier 57...
 

jmcpolin

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Modifier -57 is “decision for surgery. (It is) an E&M service that resulted in the initial decision to perform the surgery. This modifier is
used to report an E&M service that resulted in a decision to perform a major surgical procedure on the day of or the day before the surgery.”

Source: Medicare Part B newsletter # 01-020, dated Sept.1, 2001, page 15.
 

aaron.lucas

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no, in fact it would be inappropriate to use -57 in that case. I attended an AAPC workshop on the subject of modifiers a couple months ago, and we learned that decision for surgery modifier should be used really only when the surgery is same/next day, as it overrides the global package inclusion. if you review the surgery guidelines, it states under CPT Surgical Package Definition: "subsequent to decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical)" is included in the global package. this means that OVs on the day of or day prior to a major surgery (90 day global) are normally included (preop clearance, etc.). but if you made the decision (hence the modifier) on that day/day before, it's not included, so you would be able to bill separately. so only use -57 if the surgery is the same/next day, otherwise it's unnecessary and could end in a denial. hope this helps! :)
 

willette

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Thank you sooo much, I was told different at a seminar and did not agree with them!
 
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