Modifier 57 as a Decision for Surgery Modifier
Recently Betsy Nicoletti with CodingIntel completed an audit for a general surgery practice. Included in the audit were two services for an initial hospital visit on the day of an emergency surgery. Both of these were reported with modifier -25 on the evaluation and management (E/M) service and both were denied by the payer. The practice did not appeal the denials.
Experienced coders are shaking their heads as they read this. They know that the (E/M) service should have been reported with modifier 57 not modifier 25. Why? Modifier -25 is used on an E/M services on the same day as a minor surgical procedure to indicate that the E/M service was separate and distinct from the minor procedure.
A minor procedure is defined by Medicare–and this is accepted by all commercial payers—as a procedure with 0 or 10 global days. The global days are found in the Medicare Physician Fee Schedule and available in many coding programs. A major procedure is a procedure with 90 global days. An initial evaluation prior to a major surgical procedure is always payable. When this initial evaluation results in the decision for surgery on that calendar day or the next calendar day, append modifier -57 as the decision for surgery modifier to the E/M service.
Key Points to Remember for Modifier 25 vs. 57:
- Use modifier -25 on an E/M service provided on the same day as a minor procedure. Remember, the NCCI edits require that the E/M is separate and distinct, that the physician or NPP needed to evaluate a condition prior to the decision to perform the procedure. Payment for the decision to perform the procedure is included in the payment for the procedure. For example, if an evaluation for bleeding and anemia results in the decision for an endoscopy. Report both the E/M and the endoscopy.
- Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery.
- Appeal denials up to the Medical Director of the plan. A surgeon should always be paid for the E/M prior to an urgent/emergency surgery.
- Do not append modifier -57 on the E/M for the decision for surgery if the surgery is scheduled later than the day after the E/M service.
The CPT and CMS rules for using modifier-57 have not changed since I wrote this post in 2016. However, I hear from surgical practices that some private payers and some managed Medicaid companies don’t recognize modifier 57. The practices need to appeal each and every one to get the claim paid, sometimes successfully and sometimes not.
If this is happening to your practice, contact your professional association, (AOA, ACS, AAOS) and talk to them. Write to your insurance commissioner to report that the payer is not following CPT and CMS rules. Find the name of the payer’s medical director and have the surgeon in your practice call that physician.
For additional information on modifiers, watch Using Modifiers Correctly: Every claim line tells a story.
Betsy Nicoletti, Revised 09/10/18