April 2001 Bulletin

Compensation possible for preoperative H&P

But follow the rules; carriers are reporting that providers are using the modifier inappropriately

By Margie Scalley Vaught

Can compensation be received for preoperative history and physicals (H&P) when performed by the surgeon?

It all depends on the type of preoperative H&P being performed. It is unlikely that a surgeon would perform a procedure without first obtaining a history and doing an examination. It is because of this philosophy that many societies (AAOS, AMA and CPT advisory panel) agree that compensation should be obtained under certain conditions. Here are two examples:

  1. An orthopaedic surgeon is called to evaluate a patient just admitted to the hospital with a hip fracture. The orthopaedist takes a history and performs an examination. Risk, options, benefits, etc., are discussed with the patient who then opts for surgery. Surgery is performed later that day or early the next morning.
  2. An orthopaedic surgeon treats a patient in his/her office for degenerative arthritis of the knee. The patient decides to proceed with total joint replacement. This surgery is scheduled five weeks in advance. The patient is then instructed to come back the day prior to surgery for preop clearance and last minute discussion.Can the orthopaedist receive compensation for the Evaluation and Management (E/M) service performed prior to surgery? This is where modifier —57 comes into play.

According to CPT, modifier —57 states: Decision for Surgery: An E/M service that resulted in the initial decision to perform the surgery.

Correct usage of modifier —57 is "add modifier —57 to the appropriate level of E/M service that resulted in the initial decision to perform the major surgery. For Medicare claims, the —57 modifier should be used only in cases in which the decision for surgery was made during the preoperative period of a surgical procedure within a 90-day postoperative period (i.e., major surgery). The preoperative period is defined as the day before and the day of the surgical procedure."1 Incorrect usage, would be "attaching modifier —57 to the hospital visit code (or office visit code) for the day before surgery or day of surgery when the decision to perform the ‘major’ surgical procedure (as defined by Medicare) was made well in advance of the surgery."1

Medicare gives reference to issuing payment for the use of modifier —57 as follows: "Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses modifier 57 to indicate that the service was for the decision to perform the procedure. Do not pay for an E/M service billed with modifier 57 if it was provided on or the day before a procedure with a 0 or 10 day global surgical period."2

Carriers are reporting that providers are using this modifier inappropriately to get extra reimbursement for the preoperative clearance evaluation, which is included in the global surgical package. Physicians need to understand that if a procedure has been previously scheduled with the operating team (days or weeks ahead) and the patient now comes in just prior to the procedure for preop clearance, that modifier —57 is not appropriate and can result in an audit.

Example number 1 would meet the guidelines for assigning modifier —57 to that E/M service prior to surgery. However, example number 2 would not meet the guidelines because the decision for surgery was made five weeks prior to the preop clearance service.

The rule of thumb would be to use modifier —57 only when the actual decision for surgery is made during that particular patient encounter. Not all pre-operative encounters should be assigned modifier —57, especially on those advanced scheduled elective cases. Further documentation regarding the usage of Modifier —57 can be found in the September 1998 CPT assistant and September 1997 CPT assistant.

Sources:

  1. Medicode "Modifiers Made Easy" 2000 edition, pages 21-25
  2. Medicare Carriers Manual section 15504 pages 15-76

Margie Scalley Vaught, CPC, is an independent coding specialist in Ellensburg, Wash. She also is a member of the American Academy of Professional Coders National Advisory Board.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.


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