Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Modifier 57: Decision for Surgery

Policy #:

MA03.010e

Policy

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 policy applies to professional and outpatient facility claims.

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.

It is appropriate to append Modifier 57 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.

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 that is related to and part of the standard post-operative care of a 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: 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. Claims submitted with modifier 57 are subject to pre- and post-payment review and potential denials or retractions for inappropriate use.

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

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

This policy is consistent with Medicare's coverage criteria. 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 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 April 26, 2021..

Novitas Solutions, Inc. Modifier 57 Fact Sheet. 02/21/17. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144543. Accessed April 26, 2021..

Novitas Solutions, Inc. Global Surgery Modifiers. 11/01/2018. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144547. Accessed April 26, 2021..

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

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

57 Decision for Surgery

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA03.010e:

06/21/2021

This version of the policy becomes effective 06/21/2021. The intent of this policy has not changed, although it has been updated to clarify coverage requirements.

Revisions From MA03.010d:

12/16/2019

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

Revisions From MA03.010c:

01/01/2018

Policy # 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

Revisions From MA03.010b:

01/01/2017

This 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

Revisions From MA03.010a:

02/09/2015

This 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

Revisions From MA03.010:

01/01/2015

This is a new policy.

Version Effective Date:

6/21/2021

Version Issued Date: