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Railroad Medicare
CPT Modifier 57

Description:
Decision for surgery

Guidelines/Instructions:
  • This modifier may be used to indicate that an Evaluation and Management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon is significant and separately identifiable from the usual work associated with the preoperative surgical work. Documentation in the patient's medical record must support the use of this modifier.
  • E/M services on the day before the procedure, the day of the procedure and within the 90-day postoperative period are generally not payable. CPT modifier 57 may be submitted with these procedures if documentation in the patient's medical record supports its use.
  • This modifier may only be submitted with E/M and eye exam codes
  • This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99324 through 99328, and 99341 through 99345. These codes are 'new patient' codes and are automatically excluded from the global surgery package. This means that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed. In addition, this modifier is not required with CPT codes 99281 through 99285. These codes are also automatically excluded from the global surgery package.
  • E/M services on the same day as a procedure with 0 or 10 global days are generally not payable separately from the procedure. For additional information, please refer to CPT modifier 25.
  • No supporting documentation is required with the claim when this modifier is submitted
To determine the global period of a surgery, refer to the Medicare Physician Fee Schedule database (MPFSDB).
  • Access the database directly from the CMS Web site at www.cms.hhs.gov/PFSlookup/
  • Select Physician Fee Schedule Search from the left area of the Web page
  • Screen defaults to current year. Under Type of Information, select Payment Policy Indicators, then 'next.'
  • On the 'select field options' screen, select 'Next'
  • Enter the procedure code and select 'All Modifiers', then click 'Submit'
  • Refer to the column heading 'Global'
  • 000 = Endoscopic or minor procedure with related preoperative and postoperative relative value units on the day of the procedure only, included in the fee schedule payment amount
  • 010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative values during a 10-day postoperative period included in the fee schedule amount
  • 090 = Major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule payment amount
  • MMM = Maternity codes. The usual global period does not apply.
  • XXX = Global concept does not apply
  • YYY = Palmetto GBA will determine whether the global concept applies and establish a postoperative period, if appropriate
  • ZZZ = Code is related to another service ('add-on' code) and is always included in the global period of the other service

Examples for Correct Use of CPT Modifier 57
Example 1: beneficiary medical history: April 15, 2009 - removal of gall bladder (CPT code 45762, 90 global days)

  • On April 15, 2009, the patient was brought into the ER for severe abdominal pain. Due to the severity of the patient’s condition, the decision was made to remove the gall bladder after diagnostic testing was completed on the same date. The patient was admitted to the hospital on the same date; the claim for hospital admission was submitted with CPT code 99221.
  • Outcome: Submit CPT modifier 57 with the hospital admission for evaluation and planned major abdominal surgery

Example 2: beneficiary medical history: May 1, 2009 - repair of colostomy (CPT code 44620, 90 global days)

  • The patient had been hospitalized. The hospital visit CPT code 99233 was submitted on May 1, 2009, and the decision was made to reverse the colostomy the next day on May 2, 2009.
  • Outcome: Submit CPT modifier 57 with the hospital visit on May 1, 2009, for evaluation and planned major colon surgery

Reference:

 

last updated on 12/01/2009
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