Modifier 57 – Decision for Surgery
Effective Date: July 5, 2016
Implementation of this policy would provide cost avoidance by preventing E&M services involving a decision for surgery for procedures with 0 or 10 day global surgical from paying. This handling is consistent with CMS guidelines and Horizon NJ Health should be following this approach.
This policy applies to the Horizon NJ Health product.
Global payments are 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.
Horizon NJ Health does not allow payment for modifier 57 when appended to a:
- 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.
(Section 30.6.6; Part C: “CPT Modifier “57” – Decision for Surgery Made Within Global Surgical Period under Modifier 57”)
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 of 100% of the applicable Horizon NJ Health fee schedule.
E&M services billed with a Modifier 57 should be denied if billed in addition to a procedure with a “0” or “10” day global surgical procedure.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Provider Participation Agreement
- Routine Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.