Decision For Surgery
According to both CPT and Medicare, the decision for surgery is not part of the surgical package and should be separately coded using an E/M code. When the decision for surgery occurs more than one day before the day of the procedure, you can typically report the E/M code without any modifier, since neither the CPT nor the Medicare surgical package includes preoperative services that occur more than one day before the date of the procedure.
If the decision for surgery occurs the day before the procedure, you should attach modifier-57, "Decision for surgery," to the E/M code. This indicates that the E/M service resulted in the initial decision to perform the surgery and, therefore, should not be bundled in with the surgical procedure subsequently performed.
A more common scenario in family medicine involves making the decision to perform a procedure and then doing it during the same encounter. For example, a patient presents with a suspicious-looking skin lesion that the physician and patient agree should be removed at that visit. [COLOR="Red"][I]In this situation, if the E/M service that led to the decision to perform the procedure is significant and separately identifiable, the E/M service should be reported with modifier-25,[/I][/COLOR] "Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service," in addition to the code for the procedure itself.
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