Outpatient Facility Coding Alert - 2019 Issue 2
Modifiers: RACs Boost Scrutiny of Modifier 57
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Article Overview
This article covers Recovery Audit Contractors’ increased scrutiny of modifier 57 in Medicare claims and explains the compliance concerns that can arise when evaluation and management services are billed around surgical procedures. It is aimed at emergency department, hospital, and professional coding staff who need to understand the audit context, the general circumstances discussed in the article, and the types of documentation and review considerations that matter when responding to audits. The article also places the topic in the broader framework of RAC activity, audit letters, and the distinction between major and minor surgical global periods.
Why This Topic Matters
Modifier 57 can affect reimbursement and audit risk when an E/M service is linked to a decision for surgery. Understanding the article helps coders and billers recognize why RACs are reviewing these claims and why documentation and audit-response processes matter.
Article Sections
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Background
Introduces Recovery Audit Contractors and their role in reviewing Medicare claims. It also explains why the modifier is receiving attention in the audit environment.
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Understand the Issue with 57
Discusses the general circumstances under which the modifier is used and why its application is being scrutinized. The section frames the topic around evaluation and management services and surgical timing.
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Follow This Expert Advice to Avoid RAC Interest
Summarizes expert commentary and the broader documentation and audit-response themes associated with the issue. It also addresses how providers should approach audit letters and record requests.
What You Will Learn
- How RAC review activity can affect claims involving modifier 57
- The general relationship between evaluation and management services and surgical decisions
- Why documentation and audit-response processes are important in this context
- How the article frames major versus minor surgical global periods at a high level
Who Should Read This
- Medical coders
- Emergency department coding staff
- Hospital billing staff
- Physician billing and compliance staff
- Revenue integrity professionals
Codes Discussed
Modifiers Discussed
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