Notification



Notification Issue Date:



Claim Payment Policy


Title:Modifier 57: Decision for Surgery

Policy #:03.00.16n

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

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

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, the E&M service should be billed separately and appended with modifier 57 (decision for surgery) to indicate that the E&M is not part of the global surgical package.

It is appropriate to append modifier 57 (decision for surgery) to the E&M services listed in the coding table of the policy, to indicate that the E&M service performed is not included in the global surgical package. Modifier 57 should be appended to the 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 same day as or the day before a major surgical procedure.

It is inappropriate to append modifier 57 to E&M services in the following instances:
  • The Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code does not appear in the coding table of the policy.
  • An E&M service performed on the day before or the day of a major surgical procedure, when the decision to perform the procedure was made in advance of the surgery.
  • An E&M service performed on the same day as, or during the global surgical period of a minor procedure with a 0 or 10 day postoperative period.
  • An E&M service performed on the same day as a minor surgical procedure which does not include a postoperative period.

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: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and 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

The CPT/HCPCS codes listed in the coding table are reportable with modifier 57.

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

Subject to the terms and conditions of the applicable benefit contract, evaluation and management (E&M) services appended with modifier 57 are covered under the medical benefits of the Company's products.

MEDICARE

This policy is consistent with Medicare's reporting requirements. The Company's payment methodology may differ from Medicare.

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 a major surgery. In these circumstances, modifier 57 (decision for surgery) should be appended to the appropriate E&M service to denote this information.

Major surgical procedure, for the purpose of this policy, refers to a surgical procedure with a 90-day postoperative period, which begins the day after the surgical procedure. The preoperative period for a major surgical procedure includes the day before and the day of the surgical procedure.

Minor surgical procedure, for the purpose of this policy, refers to a surgical procedure with a 0 to 10-day postoperative period, which begins the day after the surgical procedure. A minor surgical procedure does not include a preoperative surgical period.
References


2010 Ingenix Learning: Understanding Modifiers. West Valley City, UT: International Standard Book Number (ISBN) 978-1-60151-280-2.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual.Chapter 12 - Physicians/Nonphysician Practitioners. 30.6.6: Payment for evaluation and management services provided during global period of surgery. [CMS Web site]. 06/01/06. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed January 10, 2011.

Highmark Medicare Services. Medicare A/B Reference Manual. Chapter 20: Coding Resources/Modifiers. [Highmark Medicare Website]. 10/19/2010. Available at: https://www.highmarkmedicareservices.com/refman/chapter-20.html#5. Accessed January 10, 2011.

Highmark Medicare Services. Medicare A/B Reference Manual. Chapter 22: Global Surgery & Related Services. [Highmark Medicare Website]. 10/19/2010. Available at: https://www.highmarkmedicareservices.com/refman/chapter-22.html. Accessed January 10, 2011.



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)

The following CPT codes are eligible to be reported with Modifier 57 (not all codes listed below are covered and eligible for reimbursement consideration):

0188T 0189T 0359T 0360T 0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T 0369T 0370T 0371T 0372T 0373T 0374T 34839 92002 92004 92012 92014 93792 93793 96160 99024 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99224 99225 99226 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99281 99282 99283 99284 99285 99288 99291 99292 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99339 99340 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99355 99356 99357 99358 99359 99360 99366 99367 99368 99374 99375 99377 99378 99379 99380 99381 99382 99383 99384 99385 99386 99387 99391 99392 99393 99394 99395 99396 99397 99401 99402 99403 99404 99406 99407 99408 99409 99411 99412 99429 99441 99442 99443 99444 99446,99447,99448,99449,99450 99455 99456 99460 99461 99462 99463 99464 99465 99466 99467 99468 99469 99471 99472 99475 99476 99477 99478 99479 99480 99483 99484 99485 99486 99487 99489 99490 99492 99493 99494 99495 99496 99497 99498 99499


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)



The following HCPCS codes are eligible to be reported with Modifier 57 (not all codes listed below are covered and eligible for reimbursement consideration):

D9311 G0101 G0102 G0128 G0175 G0181 G0182 G0245 G0246 G0247 G0337 G0378 G0379 G0380 G0381 G0382 G0383 G0384 G0402 G0406 G0407 G0408 G0425 G0426 G0427 G0436 G0437 G0438 G0439 G0463 G0473 G0501 G0505 G0506 G0508 G0509 G0513 G0514 G9050 G9051 G9052 G9053 G9054 G9055 S0260 S0265 S0601 S0610 S0612 S0613 S9117 S9123 S9124 S9140 S9141 S9455



Revenue Code Number(s)

N/A


Misc Code

Modifier:

57: Decision for Surgery



Coding and Billing Requirements


Cross References


Policy History

REVISION FROM 03.00.16n
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: 01/01/2018
Version Issued Date: 01/10/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.