When do I use the 57 modifier instead of the 25 modifier | aad.org
When do I use the 57 modifier instead of the 25 modifier?

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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Modifier 57 indicates a separately identifiable evaluation and management (E/M) service related to the decision to perform surgery; Medicare further defines surgery as a procedure with a 90-day global period. Modifier 25, on the other hand, indicates that on the day of a minor procedure (one with a 10-day global period), the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-operative care associated with the procedure or service performed.

According to Medicare, modifier 57 indicates that an E/M service resulted in the initial decision to perform surgery, either the day before or the day of a major surgery. Private payer policies may vary; while some payers prefer modifier 25 whenever an E/M service is billed on the same date as another service, you should confirm the policies of your local private payers.

To determine the global period for major surgeries, count one day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery. To determine the global period for minor procedures, count the day of surgery and the appropriate number of days immediately following the date of surgery.

In both these cases, the E/M service is provided by the same physician, either the day before or the day of a major surgery (modifier 57) or on the day of a minor procedure (modifier 25). [pagebreak]

The mere decision to perform any type of surgery does not justify a separate E/M service. According to Medicare, “both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.” When performing major surgery, the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery can justify the need to report an E/M service. The initial evaluation is always included in the allowance for a minor surgical procedure.

Example 1:

You see an established Medicare patient for a new lesion on the nasal tip. You perform an appropriate history and physical examination and upon discussion with the patient explaining the procedure, the decision is made to perform Mohs micrographic surgery with closure by means of an adjacent tissue transfer.

Mohs has a zero-day global period, but the flap closure has a 90-day global period. The E/M services provided, including the decision to perform surgery, would be reported with modifier 57. When an E/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another, unrelated procedure, the E/M service must be billed with both the 24 and 57 modifiers. [pagebreak]

Example 2:

You see a new Medicare patient with a lesion on the trunk. You perform an appropriate history and physical examination, including examination for other lesions, and make the decision to perform biopsy and curettage of the lesion.

When a suspected basal cell carcinoma is biopsied and curetted, it is appropriate to hold the claim until the pathology report is received. If the lesion proves to be a basal cell carcinoma, the only reported procedure is the destruction (reported using the size of the final curettage defect). If the lesion proves to be benign, the biopsy is the only procedure reported.

The decision to perform a procedure with a 10-day global period would not, by itself, justify a separate E/M service, but this is a new patient, and it is quite likely that the medically necessary cognitive services could justify a separate E/M code. If reported, it would be reported with a 25 modifier.

Note that when Medicare auditors review claims with modifier 25, they first identify all documentation specific to the procedure. All customary pre- and post-operative counseling as well as the decision to perform the procedure is bundled into the procedure code (for a procedure with a 10-day global period). The medical record documentation would have to sufficiently identify the separate and distinct cognitive services to justify a separate E/M code.

The auditor would consider all documentation separate from the documentation related to the procedure to determine if there is a significant, separately identifiable E/M service. Those services should be “reasonable and necessary” as defined in the Social Security Act, Section 1862(a)(1)(A).

When an E/M service resulting in the initial decision to perform a minor surgery is furnished during the post-operative period of another, unrelated procedure, the E/M service must be billed with both the 24 and 25 modifiers.