Monday, August 23, 2010

Medicare modifier 57 - when to use

Modifier 57 Fact Sheet

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.

Appropriate Usage:

• Append where the decision to perform surgery is made the day of or day before a major surgery during an E/M service

• Append only to the E/M procedure code


Inappropriate Usage:

• Appending to a surgical procedure code

• Appending to an E/M procedure code performed the same day as a minor surgery. When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure.

• Do not report for a preplanned or prescheduled surgery, or if the surgical procedure indicates performance in multiple sessions or stages.


Facts:

• Global period– The day before surgery, the day of the surgery and the number of days following the surgery as indicated on the MPFSDB. Often, a major surgery has a 90-day post-operative period and a minor surgery has either a zero or a 10-day post-operative period.

• A preoperative period is the day before the surgery or the day of surgery.

• When an E/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another, unrelated procedure, the E/M service must be billed with both the 24 and 57 modifiers.

Procedure codes:


                     92002-92014 E/M Ophthalmology Services
                     99201-99499 E/M all locations
                     99241-99245 Office/Outpatient Consultations
                     99251-99275 Inpatient Consultations


Pre-operative Period Billing

E/M Service Resulting in the Initial Decision to Perform Surgery Evaluation/Management (E/M) services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery. Therefore, these services may be billed and paid separately.

In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery.

The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure.

MACs may not pay for an E/M service billed with the CPT modifier “-57” if it was provided on the day of, or the day, before a procedure with a 0 or 10 day global surgical period.

In addition to the E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. Carriers/MACs may not pay for an E/M service billed with the modifier


Reimbursement Guidelines

An E/M service provided the day before or the day of a surgical procedure which resulted in the initial decision to perform surgery is eligible for separate reimbursement in addition to the global surgery allowance for the procedure code when all of the following criteria are met:

* The surgical procedure code is a major surgery (global period of 090 days).

*  Modifier -57 is appended to the E/M code.

*  The medical record documentation supports the use of modifier 57.

The submission of modifier -57 appended to a procedure code indicates that documentation is available in the patient’s records which will support that the E/M service resulted in the initial decision to perform the surgery, and that these records will be provided in a timely manner for review upon request.

Modifier -57 is not considered valid when the E/M service is associated with a minor surgical procedure (defined as having a 0 or 10 day global period).  If an evaluation and management (E/M, E&M) service is billed with modifier 57 appended and is identified as related to a minor surgery procedure, the service will be denied as included in the global surgery package despite the use of the modifier.

Modifier -57 should not be used when the E/M service was for the preoperative evaluation.


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