MA PPO

Modifier 57 Decision for Surgery
MA03.010d


Policy

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

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

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

Modifiers

57 Decision for Surgery

Coding and Billing Requirements



Policy History

12/16/2019
12/16/2019
MA03.010
Claim Payment Policy Bulletin
Medicare Advantage
Yes