Effective Date: October 14, 2019

Purpose:
Provide guidelines for the application of modifier -57 when appropriately billed by professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Global Payments: Fixed-dollar payments inclusive of the care that patients may receive in a given time period, such as 10 days, 30 days, 90 days, a year.
• Modifier -57: Used to indicate that a particular Evaluation and Management (E&M) service performed in the preoprerative period of a major surgical procedure resulted in a decision to perform that surgical service.
• Major surgical procedure: A surgical procedure that includes a 90-day post-operative period. Major surgical procedures also include a 2-day preoperative period.
• Minor Surgical Procedure: A surgical procedure that includes a 0- or 10-day post-operative period. Minor surgical procedures do not include a preoperative period.
• Pre-Operative Period: The day before and the day of a major surgical procedure.

Policy:
Horizon NJ Health does not allow payment for modifier -57 when appended to a:

• Evaluation and Management (E&M) services that resulted in a minor surgical procedure
• When applied to an E&M service for post-operative evaluation
• When appended to an E&M service that resulted in an ineligible surgical service

Additionally, the intended use of modifier -57 (Decision for surgery) is to represent that the decision to perform major surgery has occurred on the date of, or the date prior to, the surgery. Therefore, when a provider bills an E/M service with one of the below categories of planned surgeries, the E/M service will be denied.

Categories of Planned Surgery:

• Spine surgery (excluding fractures and dislocations)
• Arthroplasty (total, partial, revision)
• Congenital/deformity procedures (i.e. club foot)
• Chronic/sub-acute conditions (i.e. tennis elbow, cataract surgery)
• Transplant procedures

Exclusions do exist for certain E/M codes that are billed in the following places of service:

• POS 11 - CPT codes 99241-99245 (Office consultation)
• POS 21 - CPT codes 99221-99223 (Initial hospital care), 99251-99255 (Inpatient consultation)
• POS 23 - E/M codes billed within the emergency room setting

Procedure:
An E&M service that resulted in a decision to perform a major surgical service performed within the preoperative period of that major surgical procedure that is appropriately appended with modifier -57 will be considered for reimbursement at the applicable Horizon NJ Health fee schedule.

E&M services billed with a Modifier -57 should be denied by Horizon NJ Health if billed in addition to a procedure with a “0” or “10” day global surgical procedure (minor procedure).

Horizon NJ Health shall deny E/M services with modifier -57 when billed with planned major surgical services.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual, Chapter 12- Physicians/Non-physician Practitioners, Section 30.6.6; Part C: “CPT Modifier “57” – Decision for Surgery Made Within Global Surgical Period under Modifier -57 cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services