Coding experts at reputable medical coding firms are well-versed in using numerous modifiers to ensure compliance with industry standards. Modifiers offer precision and accuracy for documenting the patient encounter and are simple two-character markers that indicate how the code for the operation or service should be used for the claim. Some modifiers enhance or decrease reimbursement, whereas others provide information. If utilized incorrectly, they can result in denials, payer monitoring and audits, reimbursements, and penalties. It has been discovered that physicians are perplexed by certain modifiers, particularly those involving reimbursement.
MODIFIER 57: Decision for surgery
By attaching modifier 57 to the correct level of E/M service, you can identify an evaluation and management service that led to the original decision to do the surgery. Modifier 57 attached to a procedure code implies that documentation in the patient’s medical record exists to demonstrate that the E/M service led in the original decision to undertake the surgery and that these records will be made accessible for inspection upon demand in a timely way.
- Append exclusively on E/M visits involving procedures with a 90-day global postoperative term.
- The worldwide package for 90-day postoperative period procedures comprises the day before surgery and 90 days after surgery.
- Use if the decision to have surgery is made on the day or the day before the surgery.
- To evaluate the need for major surgery, use for first consultation or assessment of the condition by a surgeon.
- Minor procedures should not be added to E/M appointments (000 or 10-day postoperative period).
- Do not add services linked to surgery from other physicians unless the surgeon and the other physician agree on care transitions.
- Do not add E/M services unrelated to the condition for which the surgical operation is performed.
Minor and major surgical procedures
A major surgical procedure has a worldwide term of 090 days. Suppose an E&M is done on the same service date as a major medical operation to determine whether to undertake this surgical procedure. In that case, the E&M service must be reported separately with modifier 57. Other preoperative E&M services provided on the same day as a major surgical procedure are included in the procedure’s total payment and are not individually reportable.
Minor surgical surgery is characterized as having a worldwide period of 000 or 010 days. E&M services provided on the same day as the minor surgical operation are included in the treatment charge. The choice to execute a minor surgical procedure is included in the payment and should not be presented separately as an E&M service. The notion that the patient is “new” to the provider is not enough to justify recording an E&M service the same day as a minor surgical operation.
These guidelines do not apply to procedures having a global surgery indicator of ‘XXX.’ Many of these ‘XXX’ tasks are performed by physicians. They have fundamental pre-, intra-, and post-procedure work normally undertaken each time the process is conducted. This activity should never be generally separated as an E&M code. Other ‘XXX’ operations are not often performed by physicians and do not have physician task relative value units connected with them. A physician should never submit a separate E&M code to monitor others executing the processor for the evaluation of the process with these procedures.
Take note of the following:
- A preliminary evaluation before a major surgical treatment is usually reimbursable.
- Modifier 57 should be added to any E/M service performed on the day of or before a significant surgical procedure where the E/M service resulted in the determination to perform surgery. That tells the payer that the physician deemed the procedure appropriate and medically essential.
- Modifier 57 should only add to the E/M procedure code.
- Modifier 57 can be added to an initial hospital visit on the day of immediate surgery. For example, suppose a surgeon sees a patient, notes the contact properly, and advises a laparoscopic appendectomy (CPT 44970, 90-day global term) later that day.
- Most clinicians prefer to use skilled medical coding services to avoid code and modifier misunderstanding. With CMS increasing attention on modifier use, such assistance is critical to assisting clinicians in avoiding misconceptions and appropriately filing medical billing claims.
Familiarizing yourself with modifiers, such as 57, that apply to your provider ensure that the modifier is utilized correctly and receive the compensation you deserve. Billing executive has an expert coding team that applies correct modifiers to avoid denials. To learn more about our medical billing services, email us at email@example.com
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