When to Use Modifier 25 and Modifier 57 on Physician Claims When to Use Modifier 25 and Modifier 57 on Physician Claims

When to Use Modifier 25 and Modifier 57 on Physician Claims

Scott Kraft, CPC, CPMA
Senior Compliance Auditor for DoctorsManagement

This auditing and compliance “Tip of the Week” was originally published by the
National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M.

After that, the similarities end, and it is important to know the distinctions between these two modifiers.

Modifier 25 is used to indicate that a significant, separately identifiable E/M service by the same physician or other qualified health care professional was performed on the same day of the procedure or other service. Modifier 57 is defined as decision for surgery.

From those definitions, we know that modifier 57 is intended for the encounter when it is decided that a patient requires surgery.

Specifically, you use modifier 57 when all of the following conditions are present:
  • During the encounter, the physician or other provider decides that a major surgery needs to be done, and that surgery is done either on the same date of service or the next calendar day.
  • The surgery is a major surgery, meaning one with a 90-day global period.
Here are some common situations when modifier 57 is misused:
  • A surgical decision is made, but the physician continues to round with the patient daily until the surgery can be scheduled/completed. The surgeon should not append modifier 57 to the last E/M prior to the surgery as the decision for surgery is not being made – it has been made. In most instances, this same day E/M is bundled into the surgery. If other problems are addressed, modifier 25 may be indicated.
  • A procedure that has a 0- or 10-day global period.

Procedures with a 0- or 10-day global period can be separately reported by using modifier 25, assuming the E/M service is significant and separately identifiable. When the patient presents with the knowledge that the procedure is going to be done and no other conditions are addressed, the E/M is typically not supported and modifier 25 cannot be used.

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email info@drsmgmt.com.
  2. Read more: What can you expect from a coding and compliance review?
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