Coding to capture maximum revenue for major surgery E/M is always the goal. Modifier 57 can help.
Modifier 57 was designed to un-bundle an evaluation and management (E/M) service from a major global period, under the right circumstances. It would not be appropriate to append modifier 57 to surgical procedure codes or to E/M service codes performed in conjunction with minor surgical procedures.
HOW TO TELL IF THE SURGERY IS MAJOR OR MINOR:
- global periods (commonly referred to as “90-day globals”) are actually 92 days in length and include:
- the day before the procedure
- the day of the procedure
- 90 days following the procedure
Any necessary services normally completed during those 92 days are bundled into the global payment for that procedure. Modifier 57 indicates that the initial decision for surgery was last minute (i.e. decision made within 24 hours of performing the procedure). This modifier would not be necessary if the initial decision for major surgery was made prior to that 24-hour window, as the global period would not yet be in effect. Outside the 24-hours prior to procedure, the evaluation and management service would be billable without the need for an un-bundling modifier.
- global periods have two categories; zero global days and “10 day global” that are actually 11 days in length and include:
- the day of the procedure
- 10 days following the procedure
Minor surgical procedure global periods do not include preoperative services; therefore, modifier 57 would not be applicable. If the decision for surgery is made on the day of a minor procedure, which is commonplace in the office setting, the evaluation and management services related to that decision are routinely bundled into the payment for that procedure, and not separately billable.
Note: If the provider evaluates the patient for an unrelated complaint, on the same day as a minor procedure, an evaluation and management (E/M) service may be captured and modifier 25 would need to be appended, to indicate that a separate service was performed. The level of E/M code would be based solely on the documentation of those unrelated elements and would not include any work or evaluation related to the minor procedure.
During my tenure managing an incredible team of coders, I have found the way to maintain a high level of coding accuracy is to continually strive to dig deeper into coding education and tips of the trade. This helps keep you up-to-date in the world of medical coding.
About the Author
DIRECTOR OF PROFESSIONAL FEE CODING FOR HEALTHCARE RESOURCE GROUP, INC.
Teresa Tate, CPC has over 16 years of coding, auditing, and provider education experience. As the Director of Professional Fee Coding at HRG, Teresa and the HIM department are constantly coming up with solutions to the unique problems facing pro fee coding. Teresa, a true educator, is always willing to share her knowledge and experience to forward advancements in coding and the health services industry.