Tuesday, April 7, 2015

Global Surgery Modifiers 24,25,57,58,59,78,79


The following modifiers are used by physicians to indicate a billed service is not part of a global surgical package and is eligible for separate reimbursement: 

Modifier  &  Description

24  -  Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.
An excision of a malignant lesion on the left arm is performed in the office on January 10, 2009. The ICD-9-CM diagnosis code reported is 171.2. The post-operative period designated for excision code 11606 is 10 days.

The patient returns to the office on January 15, 2009 and is treated for contact dermatitis, ICD-9-CM code 692.0. The physician should report the appropriate evaluation and management code followed by the 24 modifier, e.g., 99212-24.
In order for the evaluation and management service to be payable in the post-operative period with the 24 modifier, the diagnosis code supporting the E/M service must be different from the diagnosis code reported for the previously performed surgery.

Modifier 24 should not be used for the medical management of a patient by the surgeon following surgery. Medicare recognizes modifier 24 only for the care following a discharge under these circumstances:

The care is for immunotherapy management furnished by the transplant surgeon;
The care is for critical care (99291, 99292) for a burn or trauma patient under diagnosis codes 800.0-929.9, 940.0-959.9; or
The documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery.

25  -  Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.

Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

57  -  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.

E/M services on the day before or on the day of major surgery ( 90 day global period) which result in the initial decision to perform the surgery are not included in the global surgery payment. These E/M services may be billed separately and identified with the 57 modifier.

This modifier should not be used for visits furnished during the global period of minor procedures (0 or 10 day global period ) unless the purpose of the visit is a decision for major surgery. This modifier 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 preoperative service and a visit or consultation is not billed in addition to the procedure. See modifier 25.

58 -   Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure.
Note: For treatment of a problem that required a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier 78.

59  -  Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Modifier 59 should only be used if there is no other more descriptive modifier available and the use of modifier 59 best explains the circumstances. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25

78  -  Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76).

79  -  Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79. (For repeat procedures on the same day, see modifier 76).

Global Modifiers: CPT Modifiers 25 and 57

When Is It Proper to Use Both Modifiers
This billing guide is being published to assist providers who bill for multiple surgical procedures with a mixture of 0, 10 and/or 90 global days.

Situation: 

A provider is billing for an evaluation and management service (E/M) performed on the same day as a major surgery and a minor surgery.

Example:


Initial hospital visit – 99223 (decision for surgery made on the same day)

Major Procedure – 33881 (90 global days)

Second Procedure – 34812 (0 global days)

Third Procedure – 36140 (global days do not apply)

The E/M service is included in the major and minor surgery unless the following requirements were met:

CPT modifier 25: The E/M service was performed on the same day as a minor surgery (000 or 010 global days) is significant and separately identifiable from the usual work associated with the surgery. Documentation in the patient's medical record must support the use of this modifier.

CPT modifier 57: The E/M service was performed on the same day or the day before a major surgery (090 global days) by the surgeon which resulted in the decision to perform the procedure. Documentation in the patient's medical record must support the use of this modifier.

If the criteria for CPT modifiers 25 and 57 were met the claim should be submitted as 99223-5725.

Reminders:

If a provider performs a visit in the global period of more than one surgery that has 0, 10

or 90 (and sometimes YYY) global days, the visit is included in the payment of each of the surgeries

If the provider feels the visit meets the criteria to be separately payable from one of the
surgeries, he/she must add the appropriate modifier to the visit

If he/she feels the visit should be separately payable for the additional surgeries,  he/she may need to add an additional modifier to the visit

A visit in the global period of a major surgery would require a different modifier versus a visit on the same day as a minor surgery, therefore if both surgeries were performed; two modifiers would be required for the visit

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