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Correct Use Of Modifier 57

By appending modifier 57 Decision for surgery to an E/M code, you are alerting the payer that the E/M service—on either the day of, or the day before, a major surgical procedure—was the service at which the provider determined that the surgery was appropriate and medically necessary, and is therefore not bundled to the surgery payment.

When deciding if you should append modifier 57, ask yourself, “Did the E/M service determine the need for a major procedure.” The CPT® manual doesn’t define “major” or “minor” procedures, but CMS does, and many other payers follow CMS’s lead. Specifically, CMS defines a major procedure as any procedure with a 90-day global period, as determined by the Medicare Physician Fee Relative Value File. CMS rules further require that Medicare contractors, “pay for an evaluation and management 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 resulted in the decision to perform the procedure” (Medicare Claims Processing Manual, Chapter 12, Section 30.6.6.c).

The Relative Value File, which can be downloaded from the CMS website, lists every HCPCS/CPT® code in alphanumeric order. To determine the global period for a code, locate the row containing that code and look to the column labeled “GLOB DAYS.” Codes with a “090” indicator are major procedures. A small number of codes have a “YYY” indicator. Individual carriers determine the global period for these codes: Check with your payer for details.

For example, a surgeon sees a patient and determines that patient needs an emergency appendectomy, and the documentation spells this out, clearly. The E/M led to the decision for surgery, just as the modifier descriptor indicates, and both the E/M (with modifier 57 appended) and the surgery may be reported, with separate payment for each.

For a separate E/M service that determines the need for a minor procedure (i.e., any procedure with a global period of less than 90 days), you should turn to modifier 25 Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified healthcare provider on the day of a procedure.

dballard2004

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Hello,

Can someone please clarify for me the correct use of modifier 57, please?

To my understanding, this modifer is only to be used for surgeries that have a 90 day global period attached--am I correct?

Can someone please refer me to a printed source that shows the correct use of this code?

One of my providers is questioning the use of this code. He thinks that it can be used if a patient comes into the office for skin tag removal or a laceration repair and I need some sort of reference to take back to him.

Can someone please give me an example of when 57 would be appended?

Thanks.
 
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ddebbied

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You would use 25 for an office visit with a procedure done on the same day and 57 on an E/M same day or day before for Medicare patients with a procedure done with a 90 day global.
 

rykin7600

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one more question on modifier 57

I would like to ask one more question regarding modifier 57 and E/M codes. Every where I looked and everything I have read said to apply to appropriate E/M codes. I understand how they are used, what I need to know is can a modifier 57 be used on a subsequent hospital code?
I have a surgeon who performed a surgery, three days later the patient had to return to the OR for exploration which is a 90 day global. The surgeon saw this patient earlier and decided to take the patient back into the OR, but all I have is the subsquent hospital visit. I want to bill for this service. I previously billed 99232 with modifiers 25 and 24 thinking that I was unable to bill with a 57. Can anyone tell me or show me the reference that addresses this, as the term appropriate is actually very vague?
 

badleyt

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Subsequent Visit Modifer 57

If the patient has to return to surgery due to a complication of the original surgery the subsequent visit would be considered part of the global and the surgery would be billed with a 78 modifier. If the reason for surgery is not related to the original surgery you would bill the sub visit with a 24 and 57 modifier and bill the surgery a modifier 59. Here is a good link that explains the usage of modifiers.

http://www.wpsmedicare.com/part_b/resources/modifiers/modifier_globalsurgery.shtml
 

Thameem

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Hi,

I agree with what you have explained for modifier 25 & 57 but I have a clarification if both a minor surgery and major surgery performed in the same visit, can we use both modifiers 25 & 57?

For example, an ED physician did an intermediate laceration repair (minor procedure) and a fracture reduction (major), will you code E&M level with modifier 25 & 57?
 
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