Payors may request documentation prior to payment to ensure that the visit is not associated with the required preprocedure history and physical. Modifier 57 is not to be confused with modifier 25. Modifier 57 indicates that the physician made the decision for “surgery” during the visit, but this modifier is used with preprocedural visits involving major surgical procedures (i.e., procedures associated with 90-day global periods). Since hospitalists do not perform major surgical procedures, they would not use this modifier with preprocedural visits.
Keep in mind that this “bundling” concept only applies when same-day visits and procedures are performed by the same physician or members of the same provider group with the same specialty designation. In other words, hospitalist visits are typically considered separate from procedures performed by a surgeon, and there is no need to append a modifier to visits on the same day as the surgeon’s procedure. The surgeon’s packaged payment includes preoperative visits after the decision for surgery is made beginning one day prior to surgery, and postoperative visits by the surgeon related to recovery from surgery, postoperative pain management, and discharge care.4 The surgeon is entitled to the full global payment if he provides the preoperative, intraoperative, and postoperative management.
If the surgeon relinquishes care and formally transfers the preoperative or postoperative management to another physician not associated with the surgical group, the other physician may bill for his portion of the perioperative management by appending modifier 56 (preop) or 55 (postop) to the procedure code. Unfortunately, the hospitalist is subject to the surgeon’s claim reporting. If the surgeon fails to solely report his intraoperative management (modifier 54 appended to the procedure code), the surgeon receives the full packaged payment. The payor will deny the hospitalist’s claim.