It’s essential to have in-depth knowledge of commonly used modifiers for global surgeries. Complete understanding of global surgery modifiers and their guidelines, ensures that you are billing as per coding compliance, not over-billing or under-coding. Understanding of modifiers for global surgeries, ensures that healthcare organizations are getting paid accurately while billing for all services and without fear of external payer audits. Commonly used modifiers for global surgeries are as follows:
Surgeries for which services performed are significantly greater than usually required may be billed with the -22 modifier added along with the procedure code. Surgeries for which services performed are significantly less than usually required may be billed with the -52 modifier. The biller must provide a concise statement about how the service differs from the usual and an operative report with the claim. Modifier -22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days.
Modifier -24 is used to report an unrelated evaluation and management service by same physician during a post-operative period. The physician may need to indicate that an evaluation and management service was performed during the post-operative period of an unrelated procedure. Services submitted with the -24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery. A diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable documentation. A physician who is responsible for post-operative care and has reported and been paid using modifier -55 also uses modifier -24 to report any unrelated visits.
Modifier -25 is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made. Modifier -25 is used to report a significant, separately identifiable evaluation and management service by same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patient’s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and post-operative care associated with the procedure or service that was performed. This circumstance may be reported by adding the modifier -25 to the appropriate level of evaluation and management service.
Modifier -54 and -55
Modifiers -54 and -55 are used for physicians who furnishes part of a global surgical package. Modifiers -54 and -55 are used where physicians agree on the transfer of care during the global period. Modifier -54 is applicable for ‘surgical care only’ while modifier -55 is applicable for ‘post-operative management only’. Both the bill for the surgical care only and the bill for the post-operative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.
Providers need not specify on the claim that care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the post-operative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of post-operative care occurs, the receiving physician cannot bill for any part of the global services until he has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he assumes care of the patient.
Modifier -57 can be used for Evaluation and Management (E/M) services resulting in the initial decision to perform surgery. Evaluation and management services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately. In addition to the E/M code, modifier -57 (i.e., decision for surgery) is used to identify a visit which results in the initial decision to perform surgery. If E/M services occur on the day of surgery, the physician bills using modifier -57 not modifier -25. The modifier -57 is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure.
Modifier -58 was established to facilitate billing of staged or related surgical procedures done during the post-operative period of the first procedure. This modifier is not used to report the treatment of a problem that requires a return to the operating room. The physician may need to indicate that the performance of a procedure or service during the post-operative period was:
- Planned prospectively or at the time of the original procedure;
- More extensive than the original procedure; or
- For therapy following a diagnostic surgical procedure.
These circumstances may be reported by adding modifier -58 to the staged procedure. A new post-operative period begins when the next procedure in the series is billed.
Modifier -78 can be used when billing for return trips to the operating room during the post-operative period. When treatment for complications requires a return trip to the operating room, physicians must bill the procedure code that describes the procedure(s) performed during the return trip. If no such code exists, use the unspecified procedure code in the correct series, i.e., 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated. In addition to the procedure code, physicians use modifier -78 for these return trips. The physician may also need to indicate that another procedure was performed during the post-operative period of the initial procedure. When this subsequent procedure is related to the first procedure and requires the use of the operating room, this circumstance may be reported by adding the modifier -78 to the related procedure.
Modifier -79 is used to report an unrelated procedure by the same physician during a post-operative period. The physician may need to indicate that the performance of a procedure or service during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.
Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding services. We referred Medicare manual to discuss commonly used modifiers for global surgeries, you can follow that link to know more. In case of any assistance needed in surgery billing and coding, contact us at 727-475-1834 or email us at email@example.com
Reference: Medicare Claims Processing Manual Chapter 12