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

Version Effective Date:

6/21/2021

Version Issued Date: