Tuesday, July 1, 2014

Modifier 57 Use: Understand Your Payer’s Definition of Global Period to Avoid Denials



Append modifier 57 only on an E/M code that represents the decision to perform a procedure with a 90-day global. 
 
Correct use of modifier 57 (decision for surgery) seems like a cake walk, but there are unseen rules you need to know before you attach the modifier to one of your claims. Differences in global period definitions and claims edits could invite trouble. Know what need to know to avoid denials:

Variations in Payer’s Definition of Global Period

Global surgical packages describe all services integral to a procedure as described by CPT.

Different payers have different definition of global period. CMS, along with most other payers, assigns a procedure or service to one of the following types of global surgical packages:

·         0-day: Just the day of the surgery is part of the package
·         10-day: The day of surgery and 10 days after the surgery – in total 11-day package
·         90-day: One day prior to the surgery, the day of the surgery, and 90 days after the surgery – in total a 92-day package

According to Medicare, you should append modifier 57 only on an E/M code that represents the decision to perform a procedure with a 90-day global.

What does it mean for your cardiology practice? You will find 90-day globals for procedures such as pacemaker insertion codes 33206 to 33208 or ICD insertion code 33249. Many of the commonly used procedures in cardiology such as catheterizations, normally have a 0-day global. In those cases, modifier 57 is not applicable.

Medicare as well as CPT® include, for their procedures with a 90-day global – the day of or day before surgery. However, there are exceptions as other payers, including some of the Medicaid programs, don’t include a day before surgery; as such the only thing they are worried about is E/M on the same day as the surgery.

Be well-versed with payer rules: If you do not follow their billing rules, you are most likely losing money by not billing for payable services. If you’re in doubt, use CMS/CPT rules. 

Good practice: The American Medical Association (AMA) suggests that you keep a health insurer reference log where you can include the payer’s global period definition. Additionally, you could arm your cardiology practice with the much-needed guidance – code and modifier usage advice, payer rules, global days, and everything you need to stay on the correct side of your cardiology pay by subscribing to Cardiology Coding Alert.