Wiki E/M with Modifier 57 Same Day as Mohs and Flap - Is it Billable?

TianaElyse

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Hi all, I’m looking for clarification and peer insight on the appropriate use of Modifier 57 in dermatology, specifically in the context of Mohs surgery followed by adjacent tissue transfer (flap repair).

Scenario:
A patient is scheduled for Mohs surgery in advance, based on biopsy and pathology review. On the day of surgery, the Mohs procedure is performed first. After clear margins are achieved, the provider evaluates the defect and discusses repair options with the patient. A flap repair (a major procedure with a 90-day global period) is then performed. The provider wants to bill an E/M with Modifier 57 on the basis that the decision to perform the major procedure (flap) was made after the Mohs and before the flap, in a sterile but pre-incision environment.

The provider’s stance is that this is not intraoperative, and that the Modifier 57 is appropriate because the major procedure decision was made at that point.

My understanding, based on CMS’s Global Surgery Booklet, Medicare Claims Processing Manual, excerpts from ACMS “Ask Glenn”, and definition of modifier -57, is that the decision for Mohs constitutes the primary surgical decision, and any closure that follows (even if complex) is part of the intraoperative workflow and therefore not eligible for a separate E/M.

I’d love to hear how others approach this and if there are local LCD's or payer-specific carve-outs, that would be helpful to know as well.

Thank you in advance!
 
I work in the audit side of things and I know that if I saw that, I'd be asking the provider "was there ever an option to just.... NOT do a closure?" I admit to being a smart-alecky person. Seriously, though, you're right - the Mohs is the primary surgical decision. Is their argument that it should be a separate E/M because they were able to discuss with the patient? Not every discussion with a patient is an E/M, and this situation is certainly related - directly - to the Mohs procedure and would be caught in the global period for that procedure anyway. Just my opinion though, and more experienced coders may have a different opinion.
 
I work in the audit side of things and I know that if I saw that, I'd be asking the provider "was there ever an option to just.... NOT do a closure?" I admit to being a smart-alecky person. Seriously, though, you're right - the Mohs is the primary surgical decision. Is their argument that it should be a separate E/M because they were able to discuss with the patient? Not every discussion with a patient is an E/M, and this situation is certainly related - directly - to the Mohs procedure and would be caught in the global period for that procedure anyway. Just my opinion though, and more experienced coders may have a different opinion.
It is common for a wound to heal by secondary intent, and also common to have a closure. AAPC has an article that questions, "if the diagnosis is the same, did the physician perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code?" The article also states, "If the note touches only briefly on the current issue and the need for the additional service or procedure, consider the E/M service to be part of the procedure and not separately billable." i was really hoping to see if other providers feel the same as mine as far as adding modifier -57 to the E/M.

 
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