February 25, 2019
Provide guidelines for the reimbursement of eligible services appropriately appended with Modifier 57 for professional providers.
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- ITS Home In-Network
- SHBP non-MA
All Insured Individual, Commercial medical plans, and Medicare Advantage plans, are included.
ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis.
Modifier 57: Used to report the Decision for Surgery. Providers should add Modifier 57 to the appropriate level of Evaluation and Management (E&M) service provided on the day before or day of a major surgery, in which the initial decision is made to perform major surgery. The intended use of modifier 57 is to represent that the decision to perform major surgery has occurred on the date of, or one day prior to the surgery and therefore the surgery was not planned in advance of that E&M.
Planned Surgeries: The following shall be defined as planned surgeries: 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.
Major Surgery: Includes all surgical procedures assigned a 90-day global surgery period as defined by CMS. Providers should not append modifier 57 to E&M performed the day before or the day of any minor procedures with a 0- or 10-day global surgery period. Services provided to the patient preoperatively, intra-operatively and postoperatively are considered part of the global surgical package and are included in the cost of the surgery, whether rendered by the surgeon or by members of the same medical group within the same specialty.
Horizon BCBSNJ shall consider separate reimbursement of an E&M performed one day before or on the same day of a major surgery.
Horizon shall not consider for separate reimbursement E & M codes appended with Modifier 57 for surgical procedures that have been planned in advance or when an E & M was billed by the same provider within two months of a major surgery where they E & M and surgical claims have the same primary diagnosis.
Horizon BCBSNJ’s editing rules for Modifier 57 shall be applied across providers in the same Tax Group with the same Specialty unless otherwise specified.
Horizon BCBSNJ shall reimburse E&M services appended with modifier 57 performed the day before or the day of any other major surgery at the applicable Horizon BCBSNJ fee schedule.
Horizon BCBSNJ shall deny E&M services appended with modifier 57 when the surgical procedure is included in the list of Planned Surgeries. Exclusions may apply 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 99251-99255 (inpatient consultation)
- POS 23 – E&M codes billed within the emergency room setting
Horizon BCBSNJ shall deny E&M services appended with modifier 57 when performed one day prior or the same day as a major surgical procedure when another E&M service has been billed in the previous two (2) months and the primary diagnosis for all three services is the same. Exclusions may apply for E&M services with modifier 57 billed in place of service 20 (Urgent care facility), 21 (Inpatient hospital), 23 (Emergency room-Hospital), or 24 (Ambulatory surgical center).
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider 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.
10/25/2017: Policy approved
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