Question 57 modifier if surgery already on schedule

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Hello,
I am trying to determine if it is acceptable to use a 57 modifier on the E/M code used for an exam if we already have the surgery scheduled with the surgery center.

I have two different scenarios.

1- Our doctor saw the patient 6 months ago and noticed they had a secondary cataract developing. We scheduled them to come back in 6 months for an evaluation of this and go ahead and added them to the surgery schedule for a YAG (CPT-66821).

2- A referring optometrist refers a patient for secondary cataract symptoms. We schedule them for an eval and also add them to the surgery schedule for a YAG (CPT-66821).

Would it be appropriate to use Modifier 57 since they are already "scheduled" for surgery on the surgery center schedule?

Per WPS, the definition of 57 Modifier:
Definition:
  • Indicates an Evaluation and Management (E/M) service resulted in the initial decision to perform surgery either:
    • The day before a major surgery (90 day global), or
    • The day of a major surgery
 
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In scenario 1, we would have the diagnosis of Secondary Cataract with a note to re-eval in 6 months. At that 6 month appointment, if patient meets medical necessity, the chart would state that patient would like to proceed with surgery. We would then proceed with surgery on one eye, that same day, and typically would add the 57 modifier. My concern is, that if we were to be audited, it may look like we determined before the patient was seen that they needed surgery since we have them on the surgery schedule.
 

thomas7331

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I've never heard of an auditor requesting to see a surgery schedule, and I would not consider the surgery schedule to be a part of the patient's medical record. The modifier is either supported in the provider's documentation for that encounter or it isn't.

If the record shows that the provider clearly made a decision for the surgery in advance and that the encounter the day of or day before the surgery was simply a pre-operative exam or re-check, then the auditor would disqualify that E&M as peri-operative care and not a decision for surgery. In the scenario you're describing, you haven't identified a decision for surgery - just a diagnosis and note to re-evaluate the patient in 6 months. I can't imagine an auditor arguing with your modifier in this situation if in the prior note there is no documentation by the provider that surgery was actually planned.
 
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Thank you both for your input. One of our doctors recently received a letter from Anthem requesting that he call and give an explanation as to why he was using 57 modifier so often. Anthem doesn't allow payment for same day evaluations done when surgery is performed. So when we do see these patients and the doctor wants to do surgery the same day, we know that we will not be paid for the exam. Our billers still submit the E/M code to Anthem with the 57 modifier so we can show this write off in our ledger. I was concerned that other plans may decide to start reviewing 57 modifier and wanted to make sure we are not going to have issues if we are audited.
 

Orthocoderpgu

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Anthem may be requesting records simply because your work flow does not fit the "traditional" work flow. I know that Geriatric providers bill 99214 on every single visit (almost) and that would normally be a "red flag" but for Geriatrics its normal. The take away is to just make sure that the documentation supports the coding and you will be fine even though what you do is a bit outside the norm.
 
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