The Medicare allowed amount for surgical procedures includes payment for certain services related to the surgery when furnished by the physician who performs the surgery or by members of the same group with the same specialty. This method of pricing is known as the global surgery package. The following modifiers define services that can be allowed outside of the global surgery package. You can find the definition of each modifier to determine whether the code is appropriate for an Evaluation and Management (E/M) code or if the modifier should be used with a surgery procedure code.
Definition: Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period.
The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.
Example: The patient had a cholecystectomy (90-day global period). One month following the surgery the patient gets into some poison ivy and develops cellulitis of the arm. The same physician who performed the surgery sees the patient. The physician should submit the claim with the 24-modifier added to the E/M code.
Definition: Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional 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 other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed.
A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining the level of E/M service).
The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of 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. This modifier is not used to report an E/M service that resulted in a decision to perform major surgery, can use modifier 57. For significant, separately identifiable non-E/M services, you can use modifier 59.
Example: An established patient presents for a previously planned minor procedure. During the course of the visit, the patient complains of another problem totally unrelated to the minor surgical procedure. The physician does an evaluation and management of the new complaint. The physician should submit the claim with the 25 modifier added to the E/M code.
Split Care: There are occasions when more than one physician provides the services included in the global surgical package. Payment for these services may be made to each physician when the physicians agree on the transfer of care of the patient. Sometimes, more than one physician may assume the postoperative care.
When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed the allowance for the global package. Appropriate modifiers for split care include modifier-54, modifier-55, and modifier-56.
An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. This modifier is used for major surgery only. The question to be asked is: When did the physician decide to do the surgery? If the decision was made the day of the surgery, or the day before surgery, the 57-modifier would be added to the E/M service.
Example: An orthopedic surgeon is called in on consult for a patient with a suspected fractured hip. After the physician completes the evaluation and management service of the patient’s condition, the surgeon decides the hip must be repaired that same day. The physician should submit the claim with the 57-modifier added to the E/M code to show that the decision for surgery was made that same day.
Definition: Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period
It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure, or (c) for therapy following a surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure. For the treatment of a problem that required a return to the operating or procedure room (e.g., unanticipated clinical condition), use modifier 78.
Example: The patient has a resection of the bowel with a temporary colostomy (90- day global period). Eighty days later, the colostomy is closed by the same physician. The physician should submit the claim for the closure with the 58 modifier. There is no reduction in reimbursement.
Definition: Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period.
It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, use modifier 76).
Example: The patient has by-pass surgery. Two days postoperative the patient develops hemorrhages and is taken back to the operating room by the same physician. The physician should submit the claim for the return to surgery with the modifier-78.
Definition: Unrelated procedure by the same physician or other qualified health care professional during the postoperative period.
The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79. (For repeat procedures on the same day, use modifier 76).
Example: The patient had a hip replacement (90-day global period). Two months later, the patient falls and fractures his or her arm and is seen by the same physician. The physician performed fracture care. The physician should submit the claim for the new surgical procedure with the modifier-79. There is no reduction in reimbursement.
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