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 resulted in the decision to perform the procedure. Documentation in the patient's medical record must support the use of this modifier.
  • 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. New patient codes are automatically excluded from the global surgery package. This means that they are reimbursed separately from surgical procedures.
  • 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 website
    • Select Physician Fee Schedule Search from the bottom of the web page
    • Screen defaults to current year. Under Type of Information, select Payment Policy Indicators.
    • Choose a single procedure code, multiple procedure codes or a range of codes, then enter the appropriate code(s)
    • Select modifier (or select "all modifiers")
    • Select 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 — removal of gallbladder (CPT code 47562, 90 global days).

  • On April 15 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 gallbladder 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 — repair of colostomy (CPT code 44620, 90 global days).

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

Reference

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