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).

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.

2 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.

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