Modifier 57 Decision for Surgery

Purpose:

To provide guidelines for the reimbursement of services appended with Modifier 57.

Policy:

Blue Cross and Blue Shield of Nebraska (BCBSNE) will not reimburse an E/M visit with modifier 57 done on the day of or the day before a minor procedure.

Reimbursement Guidelines:

The Plan recognizes Modifier 57-Decision for Surgery when appended to an Evaluation and Management (E&M) service to indicate the E&M service resulted in the initial decision for any major procedure (90-day global period), either the day before a major procedure or the day of a major procedure.

Modifier 57 should not be appended to an E&M code on the same day as a minor procedure (0- or 10-day global period). E&M visits are considered part of preoperative care and are included/bundled into the global fee for the minor procedure.

The determination of whether a procedure code is a major or minor procedure is determined by the current Center for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (LINK) “Global Days flag” indicator.

Modifier 57 should not be appended to an E&M service which was for the sole purpose of rendering a preoperative evaluation or to an E&M service that is associated with a major surgery that was planned in advanced or staged.

Modifier 57 should not be appended to an E&M service in the postoperative period when the decision for surgery is made to address complications resulting from the original surgery.

The decision for surgery must be documented in the medical records for the E&M service and be available upon request for review.

References:

Medicare Claims Processing Manual, 30.6.6 -Payment for Evaluation and Management Services Provided During Global Period of Surgery