Definition of Modifier 57

There are certain modifiers which should be used only with E&M CPT codes, for example 24, 25 and 27. Even Modifier 57 should be used along with E&M codes (99201-99499).  But, it is not just limited to E&M codes, this modifier can also be used along with ophthalmologic cpt codes 92002-92014 which is located in the medicine section. Modifier 57 is reported to an E&M CPT code only when a decision to perform a major surgery is made.

Modifier 57– Decision for Surgery

Read also: Coding tips for modifier 33 and 34

Difference between modifier 58 and 78

Guidelines  for CPT modifier 57

• This modifier may be used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure. Documentation in the patient’s medical record must support the use of this modifier.
• This modifier may only be submitted with E/M and eye exam codes
• This modifier should not be submitted with E/M codes that are explicitly for new patients only. New patient codes are automatically excluded from the global surgery package. This means that they are reimbursed separately from surgical procedures.
• E/M services on the same day as a procedure with 0 or 10 global days are generally not payable separately from the procedure. For additional information, please also check CPT modifier 25.
• No supporting documentation is required with the claim when this modifier is submitted

Difference between modifier 57 and 25

Modifier 25 is reported to indicate a separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. But, we are not supposed to report an E&M service routinely with every procedure. Most of the major procedures generally include the E&M services which is a part of their global package. Only when a separately identifiable service is given, then only we are allowed to append a modifier 25 to the E&M service code.

Modifier 57 is totally different from modifier 25. You can see the definition of both of them above, which will clear most of your doubts. When an E&M service prompts the physician to go for a major procedure or surgery within 90 days’ global period and within 24 hours of E&M service, modifier 57 needs to be appended along with the E&M service cpt code. Modifier -57 requests payment for an E/M service outside of the global package for a major procedure when the decision to perform the surgery was made during the E/M service.

Read also: List of modifiers used in Medical coding

Global period and Modifier 57

There are procedures which has 0, 10 and 90 days of global period. Now, when we are coding for procedures with 0 and 10 days’ global period, modifier 57 should not be appended to E&M service if it is performed on the previous or first day of the major procedure. Since, these procedures have less days of global period, Medicare does not allow modifier 57 to E&M services done before the surgery. On the contrary, for major procedures with 90 days of global period, if the physician decides for surgery before or on the first day of major surgery, modifier 57 can be used along with E&M service code. Since, it is 90 days’ global period Medicare allows to append modifier 57 with E/M code.

INCORRECT USE OF MODIFIER 57

• Appending to a surgical procedure code.
• Appending to an E/M procedure code performed the same day as a minor surgery/procedure.
• Reporting on the day of surgery for a pre-planned surgery.
• Reporting on the day of surgery that will be performed in stages or multiple sessions.
• Reporting on the E/M for the decision for surgery, but the surgery is scheduled in 2 or more days

CLINICAL SCENARIO

Example 1

A 70-year-old patient presents to an emergency room (E/R) with acute abdominal pain right lower quadrant. After a detailed history and exam, the decision is made to take the patient immediately to the OR for an appendectomy

99221-57

44950

Example 2

This is an Emergency Room visit for a 65 year old female who suffered a severe ankle trauma in a fall. Patient was found to have a displaced trimalleolar ankle fracture. Closed treatment of the ankle fracture with manipulation is recommended.

99284-57

27818-LT-54