Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifier 57 Decision for Surgery
Policy #:MA03.010d

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

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.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

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

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.
Policy Guidelines

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 MA03.010d
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 MA03.010c
01/01/2018Policy # MA03.010b has been identified for the Annual CPT/HCPCS code updates, effective 01/01/2018. The policy will be reissued as MA03.010c.

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

REVISION FROM MA03.010b
01/01/2017This policy has been identified for the CPT / HCPCS code update, effective 01/01/2017.

The following CPT codes have been added to this policy:
96160, D9311, G0501, G0505, G0506, G0508, G0509

The following CPT Codes have been removed from the policy:
99420

REVISION FROM MA03.010a
02/09/2015This policy has been identified for the CPT/HCPCS annual code update, effective 01/02/2015.

The following codes have been deleted from this policy:
99481, 99482, 99488, M0064

The following codes have been added to this policy:

34839 Physician planning of a patient-specific fenestrated visceral aortic endograft requiring a minimum of 90 minutes of physician time

99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.

G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

REVISION FROM MA03.010
01/01/2015This is a new policy.




Version Effective Date: 12/16/2019
Version Issued Date: 12/16/2019
Version Reissued Date: N/A