Misunderstood Modifiers

The Hospitalist. 2009 April;2009(04):

April 1, 2009 | The Hospitalist

Payors may request documentation prior to payment to ensure that the visit is not associated with the required preprocedure history and physical. Modifier 57 is not to be confused with modifier 25. Modifier 57 indicates that the physician made the decision for “surgery” during the visit, but this modifier is used with preprocedural visits involving major surgical procedures (i.e., procedures associated with 90-day global periods). Since hospitalists do not perform major surgical procedures, they would not use this modifier with preprocedural visits.

Keep in mind that this “bundling” concept only applies when same-day visits and procedures are performed by the same physician or members of the same provider group with the same specialty designation. In other words, hospitalist visits are typically considered separate from procedures performed by a surgeon, and there is no need to append a modifier to visits on the same day as the surgeon’s procedure. The surgeon’s packaged payment includes preoperative visits after the decision for surgery is made beginning one day prior to surgery, and postoperative visits by the surgeon related to recovery from surgery, postoperative pain management, and discharge care.4 The surgeon is entitled to the full global payment if he provides the preoperative, intraoperative, and postoperative management.

Common Modifiers Involving Hospitalist Services

25: Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. Modifier 25 is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. It may be prompted by the symptom or condition for which the procedure or service was provided. As such, different diagnoses are not required for reporting the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Report this modifier with separately identifiable visits provided on the same day as minor surgical procedures or endoscopies.

54: Surgical care only. When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services can be identified by adding the modifier 54 to the procedure number.

55: Postoperative management only. When one physician performs the postoperative management and another physician performs the surgical procedure, the postoperative component can be identified by adding the modifier 55 to the procedure number.

56: Preoperative management only. When one physician performs the preoperative care and evaluation and another physician performs the surgical procedure, the preoperative component can be identified by adding the modifier 56 to the procedure number.

57: Decision for surgery. E/M service resulting in the initial decision to perform the major surgery can be identified by adding the modifier 57 to the appropriate level of E/M service. Decisions for elective surgeries typically are made at a previous outpatient encounter. Do not append modifier 57 when this occurs.

If the surgeon relinquishes care and formally transfers the preoperative or postoperative management to another physician not associated with the surgical group, the other physician may bill for his portion of the perioperative management by appending modifier 56 (preop) or 55 (postop) to the procedure code. Unfortunately, the hospitalist is subject to the surgeon’s claim reporting. If the surgeon fails to solely report his intraoperative management (modifier 54 appended to the procedure code), the surgeon receives the full packaged payment. The payor will deny the hospitalist’s claim.