Wiki Report Modifier 57 When Clearance Not Yet Obtained?

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jshaw8808

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Hello All,

As the CPT guidelines for Modifier 57 state, "Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service [emphasis mine]," my assumption has been that, if the physician and patient make the decision to opt for major surgery during an E/M visit, but the physician makes it contingent on medical clearance, then it is nevertheless appropriate to append modifier 57 to that E/M service.

Am I correct, or is mod. 57 only to be used in those instances where medical clearance is not indicated (or the clearance exam is done during the same visit)?

It is also my understanding that one should only report mod. 57 if the surgery is scheduled for that same day (as the E/M visit) or the following day. Right?

Thanks,

James Shaw
CPC-A
 
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Did the physician make the decision for major surgery on the day before or day of the procedure and document it in their visit note? Use a modifier 57. Whether or not the physician indicated the surgery is contingent on clearance doesn't negate the fact the decision was made.

From AAPC Coder:
Append modifier 57 to an E/M service if the provider decides to perform surgery the day of the E/M service or the day before.

Modifier Explanation
Modifier 57 tells the payer that they must process the claim for the E/M service instead of including it in preoperative services in the surgical package payment.

To append modifier 57 properly, you must remember these points:

–The E/M service occurs the day of or the day before a major surgical procedure, a procedure with a 90 day global period.

–The E/M service must prompt the surgical procedure that follows.

–The E/M service must be related to the procedure that follows.

–The same provider or tax ID provides the E/M service and the surgical procedure.

Payers have different guidelines that determine reimbursement for E/M services with modifier 57, so check with individual payers for specific information.
 
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