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Thread: Need help with modifier

  1. #1
    Join Date
    Apr 2007

    Question Need help with modifier

    AAPC: Back to School
    The urologist seen a new patient in the office. He then sent her to the hospital for an outpatient procedure (the same day)52353 that is zero global. The patient was in serve pain. Can we use modifier -25 for the new patient visit and also get paid for the outpatient procedure proformed at the hospital? Or should we use -57 decision for surgery? I am afraid to use -57 because it is for major surgery not minor surgery. Or do we just bill the procedure and not the new patient visit?


  2. #2

    Cool Decision for Surgery

    PHP Code:
    Decision For Surgery
    According to both CPT 
    and Medicarethe decision for surgery is not part of the surgical package and should be separately coded using an E/M codeWhen the decision for surgery occurs more than one day before the day of the procedureyou can typically report the E/M code without any modifiersince neither the CPT nor the Medicare surgical package includes preoperative services that occur more than one day before the date of the procedure.
    the decision for surgery occurs the day before the procedureyou should attach modifier-57"Decision for surgery," to the E/M codeThis indicates that the E/M service resulted in the initial decision to perform the surgery and, thereforeshould not be bundled in with the surgical procedure subsequently performed.
    A more common scenario in family medicine involves making the decision to perform a procedure and then doing it during the same encounter. For examplea patient presents with a suspicious-looking skin lesion that the physician and patient agree should be removed at that visit. [COLOR="Red"][I]In this situation, if the E/M service that led to the decision to perform the procedure is significant and separately identifiablethe E/M service should be reported with modifier-25,[/I][/COLOR"Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service," in addition to the code for the procedure itself

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default Modifier 25

    The correct modifier to use is -25 on your E/M service. Modifier -57 is used only with major surgeries (i.e. 90-day global).

    However, it is still possible that your E/M service will be denied. If that happens, I would appeal in this case, citing the fact that this was a new patient and the decision to perform the procedure was made as a result of the evaluation.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4


    Modifier 57

  5. #5


    Since the procedure you are billing for has no global period and it is straight from office to out pt procedure, 25 is the modifier to use.

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