EM Coding Alert

Trouble deciding between modifiers 57 and 25? Here are the answers you need.

When your physician performs a significant, separately identifiable evaluation and management (E/M) service in addition to performing a surgical procedure or other type of service, you might be able to report an E/M code along with the procedure.

The rub: In order to code the E/M properly, you’ll have to choose whether to append modifier 57 (Decision for surgery) or 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).

Take a look at these FAQs about all the ins and outs of modifiers 57 and 25.

Q: Could you give a definition of modifier 57, for coding purposes?

You’ll use modifier 57 when the physician performs an E/M service and then decides to perform a “major” surgery during the same encounter, explains Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind. The surgery can also take place during that day or the next day when it is a major procedure carrying a 90-day global period.

The 57 modifier works just like the 25 modifier, indicating that the pre-procedure E/M is a separate and distinct service and should not be bundled into the global period for the major surgery, Holle continues.

Once the physician decides on surgery, however, the unrelated E/M service ends, says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M. “Under CPT rules, after the initial decision to do surgery, related E/M services are then included in the surgical code and would not be billed separately,” she reports. This would apply to E/M visits occurring the day before or the day of the surgery.

No care directly related to the performance of the procedure — such as review of history, informed consent, explaining the procedure to the patient, or informing the patient about the results and follow-up care — can be considered a separate, significant E/M service, Witt says.

Diagnosis coding myth: For claims with modifier 57, Witt says different diagnoses are not required for the E/M service and the separate procedure, but the documentation must clearly support that the E/M represents a separate, significant service.

Q: What is considered ‘major’ surgery, for coding purposes?

The global days on the procedure you code will show you if you should use modifier 57 or 25 for separate E/M services. If the procedure code has 0 or 10 global days, the procedure is considered “minor.” “All 90-day [global] procedure codes are major procedures,” Witt relays.

Q: Could you provide a clinical example of modifier 57 in use?

Consider this detailed scenario:

An established patient presents with an injury to her left shoulder. She says she was running and slipped, but couldn’t break her fall before hurting her shoulder. The patient reports pain in the left clavicle area and left upper chest area; notes also indicate swelling in the clavicle area, as well as large bruise on shoulder. The patient cannot raise her arm without wincing in pain. She has no fever.

During an examination, the patient is in obvious pain and holding onto her left shoulder. Further investigation reveals that the pain spreads to her entire left clavicle, with swelling apparent over the area of greatest pain. The patient’s range of motion is severely limited due to pain. The physician takes an x-ray, revealing a non-displaced fracture of the sternal end clavicle. To this point, notes indicate a level-three established patient E/M service.

After explaining to the patient the need to stabilize the fracture, the physician applies a clavicle splint and instructs the patient to keep the splint on for four weeks, except for when she’s bathing. The physician prescribes pain medication, schedules a follow-up visit, and tells the patient to call the office if the pain increases or the swelling does not diminish.

On this claim, you would report:

• 23515 (Open treatment of clavicular fracture, includes internal fixation, when performed) for the clavicle repair
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity) for the E/M service
• Modifier 57 appended to 99213 to show that the E/M was separate from the clavicle repair
• S42.012A (Anterior displaced fracture of sternal end of left clavicle, initial encounter for closed fracture) appended to 23515 and 99213 to represent the patient’s injury.

Rationale: The global period for 23515 is 90 days, meaning modifier 57 is appropriate for the separately identifiable E/M.

Q: So, when should I use modifier 25?

Coders should employ modifier 25 when the physician performs a significant, separately identifiable E/M service before performing a “minor” procedure, or a procedure that has a global period of 0 or 10 days, Witt explains.

Q: Could you provide a clinical example of modifier 25 in use?

Consider this detailed scenario from Holle:

A patient presents with an area of redness and swelling on her left leg. She says she hurt the leg a week ago, but the redness and swelling have gotten worse every day. The patient also has a slight fever.

An examination reveals that the patient is alert and active, with induration on her left calf. The area appears infected with pus, but there are no other areas of the skin that are concerning. To this point, notes indicate a level-three established patient E/M service.

After explaining to the patient need for incision and drainage (I&D), the physician uses a small-gauge needle to open an area of the wound and extract a large amount of serous fluid. The physician sends a culture to the laboratory and dresses the wound with antibiotic ointment and sterile dressing. He then prescribes antibiotics and recommends that the patient clean the wound with astringent soap.

On this claim, you would report:

• 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the I&D
• 99213 for the E/M service
• Modifier 25 appended to 99213 to show that the E/M was separate from the I&D
• L03.116 (Cellulitis of left lower limb) appended to 10060 and 99213 to represent the patient’s injury.

Rationale: The global period for 10060 is 10 days, meaning modifier 25 is appropriate for the separately identifiable E/M.