Billing an E/M Service after Mohs when a repair is indicated

Question:

Our Mohs surgeons sometimes perform an adjacent tissue transfer or a flap after Mohs surgery. Since they decided to do the flap after Mohs, they want to bill an E/M service with Modifier 57. I don’t think this is correct. Can you help clarify?

Answer:

The E/M service should not be reported after Mohs surgery when a decision is made for a repair, flap, or graft.  Even though a flap has a 90-day global period, the surgical decision was made to perform Mohs, the primary procedure.  The intent of the E/M with Modifier 57 for a procedure with a 90 global period is when the initial decision is made to perform the primary procedure.  The repair is secondary; therefore, billing an E/M service is inappropriate.  The discussion and recommendation for the repair is part of the pre-service work for the repair and the E/M service is inherent to the procedure. 

CMS Global Surgery Workbook says: “When the decision to perform the minor procedure comes immediately before a major procedure or service, we consider it a routine pre-operative service and you can’t bill a visit or consultation with the procedure. MACs may not pay for an E/M service billed with CPT modifier –57 if it’s provided on the day of, or the day before, a procedure with a 000- or 010-day global surgical period. “

Source: https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

*This response is based on the best information available as of 12/5/24.