Coding experts in established medical coding companies are well-versed in the use of various modifiers to comply with industry guidelines. Simple two-character designators that indicate how the code for the procedure or service should be applied for the claim, modifiers add accuracy and precision for recording the patient encounter. Some modifiers increase or decrease reimbursement while others are only informational. If used incorrectly, they can lead to denials, payer scrutiny and audits, refunds, and penalties. It is found that physicians are confused about certain modifiers, especially those that involve reimbursement. One example is modifier 57.
Modifier 57 describes the Decision for Surgery: indicates that 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.
This has led to the belief that this is just a modifier that signals a decision for surgery. A recent AAPC report focused on clearing the confusion and clarifies that modifier 57 should be used when the physician determines the need for any major procedure, regardless of whether it surgical or non-surgical.
Private payers go by the guidelines of the Centers for Medicare & Medicaid Services (CMS) with regard to the definition of minor and major procedures. A major procedure is defined as a procedure with 90 global days. Medicare contractors are required to pay for an evaluation and management (E/M) service on the day of or on the day before a procedure with a 90-day global surgical period if CPT modifier 57 is used to indicate that the service resulted in the decision to perform the procedure. An E/M service that takes place prior to the decision for surgery or the E/M service at which the decision for surgery is made is not bundled to the surgery payment.
Points to note:
- An initial evaluation prior to a major surgical procedure is always payable.
- Modifier 57 should be appended to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to perform surgery. This informs the payer that the physician determined the surgery was appropriate and medically necessary.
- Modifier 57 should be appended only to the E/M procedure code.
Modifier 57 can be appended to an initial hospital visit on the day of an emergency surgery. For instance, suppose a surgeon sees a patient, appropriately documents the encounter, and recommends a laparoscopic appendectomy (CPT 44970, 90-day global period) be performed later that day. In this case:
- The E/M visit resulted in the initial decision to have surgery and is therefore separately payable
- It is appropriate to use CPT modifier 57 in this case.
Another example is non-surgical fracture care which has a 90-day global period. Closed treatment of a clavicle fracture, (both CPT 23505-with manipulation, and CPT 23500-without manipulation), is not a “surgical” procedure, but is a major procedure that has a 90-day global period. In this case, when properly documented, separate payment of an E/M service with modifier 57 is appropriate.
Modifier 57 should not be:
- Appended to a surgical procedure code
- Appended to an E/M procedure code performed the same day as a minor surgery. If the decision to perform a minor procedure is made immediately before the service, it is regarded as a routine preoperative service and is not billable in addition to the procedure
- Reported on the day of surgery for a preplanned or prescheduled surgery
- Reported on the day of surgery if this procedure is one that will be performed in multiple sessions or stages
- Reported on the E/M for the decision for surgery if the surgery is scheduled later than the day after the E/M service
To avoid confusion related to code and modifier use, most physicians opt to rely on expert medical coding services. With CMS increasing scrutiny about modifier use, such support is crucial to help physicians avoid misunderstandings and file medical billing claims correctly.