Forum - Questions & Answers

Nov 11th, 2010 - DawnMarie

Modifier 57

Where can I read about the decision for surgery and how much of it is separately billable.
There are two thought processes here and I am seeking a clear cut answer if possible. I am making up this scenerio:
Patient comes in today to Orthopedics after falling at the playground and after a thorough documented E/M 99214, the provider decides that this patient requires immediate corrective surgery for their fractured radius/ulna. So we add a Mod -57 and then we bill the procedure w/a 90 global period. My understanding is that we can bill the entire 99214-57 and we can bill the 25575. Someone else in my office believes we need to carve out a portion of the 99214-57 as part of the 25575 and lower the level of service as an intricate portion of 25575 and I have not been successful in finding a clear answer either way. Please help! :) Thank you!

Nov 11th, 2010 -

that is just plain silly!

You are correct, of course. There is no carve-out- I have only heard that done when you are doing a Medicare physical (which is not covered) and an E&M visit which is covered.

You won't find a reference that says there is no carve out but here is the CMS explanation of -57 and another great explanation.

http://www.wpsmedicare.com/part_b/education/modifier_57.pdf

http://nyssmoh.blogspot.com/2008/12/ngs-news-modifier-25-and-57.html

Nov 11th, 2010 -

-25 vs -57

I am giggling because those are the two articles I just read prior to posting my question.
I don't think it is necessarily a silly question as I believe her understanding is more along the lines of, "when a patient comes in and has an E/M w/a Mod -25 and a determination has to be made if it is considered separately identifiable, than it should be done w/a Mod -57" and she has been through multiple audits w/an audit team that has taught her this model. However, my thought process on that is this:
If the patient came in a week prior and was seen and a decision for surgery were made on that day, the E/M would stand along (the same way it does the day of or the day prior to surgery except you wouldn't use a Mod -57) therefore you could bill the entire E/M so why not on the day of or the day prior?
This is why I am looking for something cut and dry in an article so that we can put this to rest. Interestingly enough, she and I are very much alike in the sense that we won't back down until we come across supporting evidence, but when we do come across the evidence, even if it does not support our current belief, we are both willing to accept the new information
I greatly appreciate your response! Thank you!
Please share your thoughts or comments?

Nov 11th, 2010 -

Can you prove Santa Claus does not exist?

The AMA and CMS would publish an advisory saying that you should carve out the fee if that was the case but they are not going to publish an article saying that you do not carve out the fees. Why would they? They can't publish a list of everything we should not do, especially when it we do it they save money.

Your reasoning is correct- the doc is doing a full evaluation for the first time. It just happens to be the day prior to the procedure and they deserve the full fee. If they saw the patient last week, decided to do surgery and brought them back to the office the day prior to do the H&P, then they do not deserve a full E&M visit- they already had the information and that visit is more administrative so bundling it into the surgical global is reasonable.

Nov 11th, 2010 -

Re: Santa

I have actually seen him, with my own two eyes, which would remind me to not believe everything I see and not believe everything I think, thus, as a CODER, I research until I find the most supportive, most logical information. :)
Thank you for your help, you are most entertaining and informative. Have a blessed day. ~Dawn Marie

Nov 11th, 2010 -

So now I need Nancy and Editor to help

Come on ladies, how can you help? Nancy has a HUGE repository of information and Editor knows everything...

Nov 11th, 2010 - nmaguire   2,606 

question

What exactly is the issue?

Nov 11th, 2010 - nmaguire   2,606 

ok

ok, I see it now. More to come

Nov 11th, 2010 - nmaguire   2,606 

Carve-out

I have not heard anyone “carve out” the small portion of E/M included in minor procedures (ex, vitals, allergy to meds, duration). The physician must evaluate especially if a new patient.to determine whether or not he will in fact perform a procedure. There used to be a code 99025 that described an E/M for the initial (new patient) visit when the starred (*) surgical procedure constitutes major service at that visit. Starred procedures no longer exist but you catch their drift. Medicare uses global surgery indicators, to indicate the care that a procedure includes. For minor procedures, example cerumen removal, which carries a “000? indicator meaning zero global days, Medicare includes related preoperative and postoperative care on the day of the procedure. Medicare also uses “010,” 10 global days, to indicate that the minor procedure contains pre- and postoperative care provided on the day of the procedure and 10 postoperative days. Therefore, if you report an E/M in addition to a minor procedure, the E/M must represent work that is not included in the procedure (ex, questions asked only to determine if procedure will be performed) hence a significant, identifiable service.
Modifier -25, when you use this modifier, you’re telling the payer that the E/M performed entails more than the small E/M included in the minor procedure. I have conducted audits for the OIG and have had many discussions regarding E/M levels of care and modifiers. At no time did they ever have this as an issue (carve out, excluding of course the Critical Care timed codes). Anyone can take the ultra-conservative interpretation and that is their right but if no guidelines exist that specifically state you need to “carve-out” of a medically necessary E/M, when using modifier -57, as an example, work attributed to the major surgical procedure, I disagree. A 90 day global includes the pre-op day, surgery and the post-op care. If the decision to perform the major procedure was made on the day before or day of a major procedure, that E/M should be paid in full for the level documented, no carve-out. There are RVUs for the pre-op %, surgery %, and post-op care %, that speaks to each being a separate piece of the whole pie.
Medicare’s Internet Only Manual, section 40.2, instructs carriers, “Pay for an E/M 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 was for the decision to perform the procedure.”

Nov 11th, 2010 -

See??

I told you Nancy would come through!!!!

Medicare’s Internet Only Manual, section 40.2, instructs carriers, “Pay for an E/M 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 was for the decision to perform the procedure.”

I love Nancy and Editor ;-). When I come up with off the cuff answers, they throw out the citation to back me up.

Nov 11th, 2010 -

Modifier 57

Thank you both for your help on this topic! I greatly appreciate all of this helpful information!!!

Aug 9th, 2011 -

secondary paid after medicare carve out

Hello,

When a secondary payer pays after you take the carve out - can you keep what was allowed and paid for or do you have to refund the secondary?



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