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Modifier 57

Lisa Posted Mon 10th of February, 2014 15:53:52 PM

If a patient presents to ER and has a heart catherization and the findings are abnormal and a consult is requested for the cardiothoracic surgeon, can the the surgeon bill an appropriate e/m on same day/day before procedure with modifer 57? The cardiologist recommendation is likely surgery and the surgeons first encounter with the patient is the same day or day prior to surgery.

SuperCoder Answered Tue 11th of February, 2014 15:04:43 PM

Assuming we’re talking about a decision to perform a 90-day global procedure like CABG, this does sound like a likely use for mod 57.

“Carriers pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier “-57” to indicate that the service resulted in the decision to perform the procedure.”
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Chapter 12
30.6.6.C
Medicare Claims Processing Manual

To append modifier 57 properly, remember these points:
• The E/M service occurs the day of or the day before a major surgical procedure (a procedure with a 90-day global period).
• The E/M service must prompt the surgical procedure that follows.
• The E/M service must be related to the procedure that follows.
• The same physician (or tax ID) provides the E/M service and the surgical procedure.

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