Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 57 Decision for Surgery

Policy #:03.00.16o


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

When the initial decision to perform a major surgical procedure is made during an evaluation and management (E & M) service that occurs the day before or the day of a major surgical procedure (assigned a 90-day global period), the E & M service should be billed separately and appended with modifier 57 to indicate that the E & M is not part of the global surgical package and is therefore eligible for separate reimbursement consideration by the Company.

APPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIER 57

Modifier 57 should be appended to an E & M service when both of the following occur:
  • The E & M service resulted in the initial decision to perform a major surgical procedure.
  • The E & M service is performed on the day before or same day of the major surgical procedure.

INAPPROPRIATE CIRCUMSTANCES FOR REPORTING MODIFIER 57

It is inappropriate to append modifier 57 to an E & M service in the following instances:
  • An E & M service performed on the day of a major surgical procedure that has been pre-planned or pre-scheduled.
  • An E & M service performed on the day of a major surgical procedure performed in multiple sessions or stages.
  • An E & M service performed on the same day of a minor surgical procedure (assigned a 0 or 10 day global period).
  • An E & M service performed following the major surgical procedure.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Guidelines

BENEFIT APPLICATION

This policy is consistent with Current Procedural Terminology (CPT) and Centers for Medicare & Medicaid Services (CMS) reporting requirements.

Description

There are circumstances in which the initial decision to perform a major surgical procedure is made during an evaluation and management (E & M) service that occurs on the day before or the day of the major surgical procedure. In these circumstances, modifier 57 is used to report the appropriate E & M service to indicate this decision.


As defined by the Centers for Medicare & Medicaid Services (CMS) and applied by the Company, reimbursement for a surgical procedure includes a standard global surgical package, which includes preoperative, intraoperative, and postoperative services.


References


Centers for Medicare and Medicaid Services (CMS). MLN Booklet: Global Surgery Booklet. [CMS Web site.] September 2018. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf. Accessed October 10, 2019.

Novitas Solutions, Inc. Modifier 57 Fact Sheet. 02/21/17. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144543. Accessed October 10, 2019.

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed October 10, 2019.

Optum360. Understanding Modifiers 2019. West Salt Lake City, UT: Optum360; 2018.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifier:

57 Decision for Surgery



Coding and Billing Requirements


Cross References


Policy History

REVISION FROM 03.00.16o
12/16/2019This version of the policy becomes effective 12/16/2019. It reaffirms the Company's continued position on reporting of modifier 57.

REVISION FROM 03.00.16n
01/01/2018Policy # 03.00.16m has been identified for the Annual CPT/HCPCS code updates, effective 01/01/2018. The policy will be reissued as 03.00.16n.

CPT
The following CPT codes have been removed from the policy:
99363 and 99364

The following CPT/HCPCS codes have been added to this policy:
93792, 93793, 99483, 99484, 99492, 99493, 99494, G0513 and G0514

Effective 10/05/2017 this policy has been updated to the new policy template format
Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A



2017 AmeriHealth.