Part B Insider (Multispecialty) Coding Alert

Published on Tue Nov 11, 2008 PDF

Know the right modifier or forfeit your pay when the physician provides a service and an evaluation on the same date of service.

Question: I have never really understood what separated modifiers 25 and 57. Could you explain the difference between them, and when I should use each?

Answer: Look at the procedure's global days to determine whether you must append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or 57 (Decision for surgery) to the E/M code.

Use modifier 25 when: The physician provides an E/M, and then performs a minor procedure (meaning one with a 0- to 10-day global period).

For example, a patient reports to the practice with a cut on her left forearm. After performing a level-two E/M, the physician makes a 7.9 cm simple repair to the cut. On the claim, you would report the E/M code (such as 99212, Office or other outpatient visit...) with modifier 25 appended, along with the code for the repair, such as 12004 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm).

Use modifier 57 when: Suppose the physician provides an E/M, and then performs a major procedure (meaning one with a 90-day global period).

For example, an established patient reports to the practice complaining of severe shoulder pain. During a level-four E/M, the ED physician determines the patient has a dislocated shoulder. The physician performs a shoulder reduction. On the claim, you would report 99214-57 (... a detailed history; a detailed examination; and medical decision making of moderate complexity ...) and 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia).

If the physician is not providing follow-up care for the patient, remember to append modifier 54 (Surgical care only) to 23650.