Did you know that there are different levels of E/M services due to various clinical scenarios? Insurance companies require details about each scenario, including those where crucial decisions are made, to reimburse the service appropriately. But how do healthcare providers communicate this information? Through modifiers, of course!
Modifier 57 is one of the most commonly used two-digit codes. Billing teams use it to differentiate special visits from routine pre-operative care. Let’s simplify this modifier so you can receive separate payments for consultations that result in significant decisions.
Modifier 57 – Description
Tired of insurance companies bundling your special E/M services into the global surgical packages? Use modifier 57! It simply specifies an Evaluation and Management (E/M) service where the initial decision to perform surgery was made. Healthcare providers can make this decision during the pre-operative period, which is usually a day before the surgery or the day of the operation.
Although it has a straightforward description, modifier 57 is quite confusing for many healthcare providers. Want to append this modifier correctly? Keep a few things in mind. You can only use this modifier with those E/M services that lead to a doctor deciding to perform a major procedure.
Here, a procedure can either be surgical or non-surgical. But it must fulfill one condition. According to CMS guidelines, it must have a 90-day global period, including pre-, intra-, and post-operative services.
Modifier 57 – Examples
Don’t want to risk your revenue? Apply modifier 57 correctly! If you are still confused, take a look at the following examples:
E/M Visit Leading to Hysterectomy Decision
A woman visits the emergency department a week after childbirth due to abnormal vaginal bleeding. The doctor diagnoses a postpartum hemorrhage after a thorough evaluation and decides to perform an emergency hysterectomy procedure (CPT code 58150) that day.
He later bills this emergency department E/M service with modifier 57 to indicate that the visit led to a major surgical decision. The doctor codes the visit as:
E/M CPT code: 99285-57
E/M Visit Resulting in Hip Replacement Surgery Decision
A senior citizen with persistent hip pain sees an orthopedic surgeon. After a detailed analysis, including imaging and physical tests, the doctor decides to perform a hip replacement surgery (CPT code 27130) the following day.
During the billing process, the orthopedic uses modifier 57 with the E/M code to request separate payment for this visit. He codes the service as:
E/M CPT code: 99205-57
E/M Service Concluding in Appendectomy Decision
Let’s consider another example. A patient with severe abdominal pain visits the ER. The doctor thoroughly evaluates the patient and conducts several tests to find the core problem. He diagnoses acute appendicitis (inflamed or swollen appendix) and decides to perform an emergency appendectomy (CPT code 44950) to prevent it from rupturing.
Since this was not a routine checkup, the billing team used modifier 57 with this E/M visit’s code to indicate that it led to a major surgical decision. As a result, the insurance company does not confuse this service as part of the global surgical package.
E/M CPT code: 99284-57
Accurate Usage Guidelines for Modifier 57
Just like every other modifier, you must use modifier 57 appropriately to avoid billing complications. As mentioned earlier, healthcare providers often misapply this modifier due to confusion. We don’t want you to do the same. Hence, we are highlighting appropriate and inappropriate uses of this two-digit code.
Appropriate Uses of Modifier 57
The following are the appropriate conditions for using this modifier:
E/M Service Resulting in Major Surgical/Non-Surgical Decisions
Insurance companies only accept modifier 57 with E/M services that result in major surgical decisions. The keyword here is “major”. It means you can apply this modifier to those E/M service codes where the doctor decides to perform a significant surgical or non-surgical procedure that has a 90-day global period.
Pre-Operative Period
Timing is another condition. This non-routine E/M service must occur during the pre-operative period of the major procedure. It means that the doctor must decide to perform surgery either a day before the operation or on the same day.
Medically Necessary
Lastly, you can only apply modifier 57 if the Evaluation and Management (E/M) service reflects the critical decision-making process. In simple words? It is not a routine checkup. This E/M service should be necessary for decision-making and result in a significant surgical or non-surgical procedure.
Inappropriate Uses of Modifier 57
Avoid using this modifier with the following codes or services:
Procedural Codes
Modifier 57 is only applicable to E/M codes. Most practices and physicians face claim denials because they append this modifier to procedural codes.
E/M Services Resulting in Minor Surgical Decisions
Avoid using modifier 57 for minor procedures. Insurance companies do not accept this modifier with Evaluation and Management (E/M) services where the doctor decides to perform a simple operation—surgery with a 0 or 10-day global period.
Routine Visits
Keep in mind that insurance companies bundle pre-operative visits for pre-planned or staged surgeries into the global surgical package. Hence, avoid using modifier 57 with routine E/M services to receive a separate payment.
Just keep these conditions in mind while using this modifier Also, make sure to document everything about the E/M service, including clinical reasoning for the surgery, to improve the chances of receiving complete reimbursements.
Modifier 57 vs 25 – Understanding the Difference
Confused between modifiers 57 and 25? Let us highlight their two key differences:
Purpose
Although both modifiers are used with an E/M service code, they are quite different. You can only append modifier 57 to E/M service codes when a doctor evaluates a patient and decides to perform a major procedure.
In contrast, modifier 25 refers to separate and significantly identifiable E/M services performed on the same day as the other procedure or service. This modifier indicates that even though the E/M service was provided by the same physician, it has no connection with other procedures performed on the same day.
Timing
Modifier 57 is used for evaluation and management (E/M) services that occur either a day before or on the same day as a surgical procedure. In contrast, you can only apply modifier 25 to E/M services performed on the same day as an unrelated minor procedure or service.
Summary
By now, you must be familiar with the correct use of modifier 57. This modifier has a simple explanation, but due to confusing conditions like major and minor procedures and timing, many people misapply it and experience claim denials.
This modifier is only applied to E/M codes at one condition: the service must result in the decision to perform a ‘major’ procedure. The procedure does not need to be surgical. You can also append this code to E/M services that result in significant non-surgical procedures. We have provided all the details about modifier 57, including its detailed description and real-world examples, to help you master its appropriate use.
