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Modifiers 25 and 57: A Quick Lesson

When a patient is seen for a new condition/diagnosis and a procedure is rendered that day, you should report the evaluation and management (E/M) visit with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended.
Do not report an E/M service routinely with every procedure. Most procedures include an element of E/M; therefore, the E/M service must be able to stand by itself as a truly significant and separately identifiable service to append modifier 25 appropriately.
For Medicare and other payers (check with your individual private payers for guidance), you should append modifier 57 Decision for surgery—rather than modifier 25—if the E/M service prompts the decision to render a major procedure (defined by Medicare as a procedure with a 90-day global period) within 24 hours of the E/M service. Modifier 25 is appropriate when an E/M service is provided on the same day as a minor procedure (defined by Medicare as having a 0-day, 10-day, or “xxx” global period).

John Verhovshek
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About Has 577 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

8 Responses to “Modifiers 25 and 57: A Quick Lesson”

  1. Sue Pinney says:

    If the doctor does an initial inpatient hospital exam and reads an echocardiogram on the same day, I would normally bill both codes and append the 25 modifier to the E&M but in this case, a pacemaker was placed the next day, which has a 90 day global period. From the E&M and the echo, the doctor made a decision to do the surgery, so my question is can I append both the 25 and the 57 modifier to this E&M?

  2. Lynda Barber says:

    I was wondering if a provider should submit a report when ever billing with a modifier 25 or 59? I work in a department that we pay claims. All the providers what to bill with these modifiers but never submit a report with it.

  3. Ashik says:

    If the doctor is performing E and M service today and he is planning to do a surgery the next day which exceeds 24 hours from the E and M service. Which modifier needs to be appended to the E and M service to get the payment for both E and M service and Surgery?

  4. bharathi tamilvanan says:

    25 and 57 modifiers append on same E&M on same day ?

  5. Chris says:

    In the ER if both a 90 day global procedure done (say fx care or reduction) and a simple repair on different body site
    do we use both 25 and 57 on the EM?

  6. Brittany P. says:

    Patient had an Injection 20610 on the same day as 99214, and patient had surgery the very next day. When 99214 was billed with 25 modifier it was denying Global to patient next day surgery, we removed and billed with 57 mod and it denied as Global to 20610, can we use both 25 and 57 modifier.

  7. dlp says:

    this response does not accurately or completely answer any of the questions above. It is a generalized statement about when and why to apply the modifiers 25 and 57 which are already explained in detail in coding books. The question remains WHEN is it appropriate to bill BOTH at the same time?

  8. Erica Deschaine says:

    can providers bill an e/m for a 4 week follow up for a cast reapplication, if everything is healing as planned?
    if not…. what if they order xrays ? Can they get an OV with the cast reapplication in that scenario?