Part B Insider (Multispecialty) Coding Alert

Published on Fri Oct 01, 2010 PDF

Medicare carriers don't require you to append both modifiers.

Myth: Payers "don't like" modifier 57 (Decision for surgery), so it's okay to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) instead.

Reality: You should append modifier 57 to an E/M service that occurs on the same day, or on the day before, a major surgical procedure, and which results in the physician's decision to perform the surgery.

Scenario: Suppose your physician performs an E/M service followed by three major procedures. You erroneously append modifiers 25 and 57 to the E/M code.

Correct coding: Medicare payers should accept the claim with modifier 57 appended to the E/M code if the documentation supports it. You shouldn't have to append both modifiers.

Direct from the source: Medicare's Internet Only Manual, section 40.2, instructs carriers, "Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier 57 to indicate that the service was for the decision to perform the procedure."

Since the physician is billing just one E/M service, only one modifier -- 25 or 57 -- is necessary. You'll use modifier 25 if the procedure being done is a minor procedure, meaning it has zero to 10 global days. When you use this modifier, you're telling the payer that the E/M performed entails more than the small E/M included in the minor procedure.

Modifier 57, however, tells the payer that the physician made the decision to perform a major surgery (with a global procedure of 90 days) at that particular E/M service.

Because procedures with 90-day global periods include E/M services performed the day of the procedure and the day before the procedure, you must append a modifier if the physician performs an E/M service and decides to do a procedure that he had not already scheduled and planned.

For a separate and significantly identifiable E/M service that occurs on the same day as a minor procedure (any procedure with a zero- or 10-day global period), you should append modifier 25 to the appropriate E/M service code.

Don't mix your modifiers: The IOM specifically instructs carriers not to pay for an E/M service "billed with the CPT modifier 57 if it was provided on or the day before a procedure with a zero- or 10-day global surgical period."

Important: Be certain that the E/M service was significant, separately identifiable, and medically necessary before you append either modifier to it.