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.

CPT® Update: 92070 Doesnâ??t Allay to Therapeutic Contacts Anymore

New Text module

Novel codes 92071 and 92072 are to be used for lens prescriptions for keratoconus and OSD.

Even though you can't bill Medicare for consistent refractive lenses, savvy ophthalmology coders are aware of the fact that you can anticipate reimbursement for contact lens prescriptions for treating keratoconus (ICD-9 codes 371.60-371.62) as well as ocular surface disorders (OSDs) for example corneal abrasions or dry eye. On the other hand, what coders at present know is changing in 2012, with the removal of one familiar code and the introduction of two novel medical CPT codes. Read on this expert insight on accurate medical Supercoder coding.

92070 no more: The medical CPT 2012 manual scrubs the ophthalmology coder's standby meant for therapeutic contact lenses, 92070 (Fitting of contact lens for treating disease, including supply of lens). As an alternative, you'll find two novel codes:

92071 (Fitting of contact lens for treatment of ocular surface disease)

92072 (Fitting of contact lens for treatment of keratoconus, initial fitting).

Notes in the medical CPT® manual warn you against reporting 92071 with 92072. For the supply of lenses, which was included in the code previous to 2012, CPT® recommends reporting 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or other materials provided), or another suitable supply code.

A note associated with novel code 92072 instructs coders to report an apt 92002-92014 (E/M or General Ophthalmological Services) code for following listed fittings of keratoconic lenses.

Difference in Ophthalmologist's Work Means Difference in RVUs

Why the change? Ophthalmologists were earlier using 92070 to report two very dissimilar kinds of service. Upon assessment of this service, the specialty societies approved that there are two distinct uses for medical CPT® code 92070 that have significantly dissimilar levels of work.

The medical CPT® Editorial Panel decided and removed CPT® code 92070 and then created two novel medical CPT codes (92071 and 92072) to differentiate reporting fitting of contact lens meant for management of ocular surface disease and fitting of contact lens for supervision of keratoconus.

To echo the fact that managing contact lens of keratoconus involves more work for ophthalmologists than treatment of OSD, Medicare has allocated more work RVUs to 92072 (1.97 work RVUs) as compared to 92071 (0.61 work RVUs). The work RVUs for 92071 are alike the work RVUs assigned to 92070 in 2011, sans a small number of adjustments in pre- as well as post-service time.

CPT® : Ascertain Whether A Patient is New With CPT®'s Newest E/M Tweaks

Get acquainted with new thoracoscopy CPT 2012 codes.

It's a long-standing debate--once an established patient visits your practice in order to see a new physician, then should you report a novel patient office visit code? CPT® 2012 tries to make clear when that's possible with a revision to the "New and Established Patient" segment of the CPT® manual. Read this article for accurate medical coding and know what the new CPT 2012 codes are.

The rules: At present, Supercoder CPT® points out that a "new patient" refers to a patient who has not received any professional services, for instance an E/M or another face-to-face service from the physician or physician group practice -- in the similar physician specialty -- in the past three years.

Clarification: CPT® 2012 takes that definition a step ahead, now maintain that a new patient is one who has not obtained any professional services provided by physician or any other physician of the exact similar specialty and subspecialty who is from the same group practice, in the past three years. The parts of the description that are new for 2012 are underlined.

What this means to you: In case your practice employs a variety of subspecialists, CPT® now clarifies that claims for patients who see dissimilar doctors with diverse subspecialties can be billed using a new patient code (such as 99201-99205)

Example: A cardiology practice makes use of a general cardiologist and an electrophysiologist (EP), and then both physicians are categorized as these different specialties with their payers. The cardiologist refers a patient to the EP for consideration of an implantable cardiodefibrillator. In this condition, the visit with the EP must qualify as a new patient visit, supposing the payer accepts these CPT® rules.

CMS Offers Surprise 0-Day Global to New Thoracoscopy CPT2012 Codes

Not only did CPT® 2012 modifies the heading of its "Thoracoscopy" part to cover the term "VATS" (video-assisted thoracic surgery), it also introduced three new diagnostic thoracoscopy CPT 2012 codes (32607, 32608, 32609)

It's an interesting fact that these new CPT 2012 codes were allocated fewer global days than even the CPT® Advisory Committee recommended.

You must keep in mind that Diagnostic thoracoscopies (32607-32609 ) actually have zero-day globals. In fact it's there in a recommendation to modify those to ten-day globals which would reveal the time the patient spends in the hospital which could be up to ten days, but that has not up till now changed. Consequently, physicians can independently report E/M services that they offer to patients all through the related hospital stay, apart from the real day of the procedure itself.