Procedure Coding: When to Use The 57 Modifier

Procedure Coding: When to Use The 57 Modifier

This is part of the Modifier Series, the articles include:

The 57 modifier is an ongoing source of confusion for physicians and medical staff alike. But it’s not so difficult once you really understand how it should be used. It is more than just another informational modifier – it actually affects reimbursement.

Correct use of modifier 57 is similar to how modifier 25 is used, a modifier which you may be more familiar with and was examined in another article in this series. Whereas modifier 25 is more appropriate for E/Ms performed in addition to minor procedures, modifier 57 is reserved for E/Ms that result in major procedures. Let’s take a moment and review when to correctly use the modifier 57 to ensure your practice is getting paid for all the services they render.

Defining Modifier 57

It’s generally understood that modifier 57 applies to an E/M from which a “decision for surgery” has been made by the physician. But there’s something more you should know. Surgical procedures aren’t the only procedures where modifier 57 can and should apply. In fact, the CPT manual states modifier 57 can be used on any E/M during which the physician decides a “major” procedure is necessary.

While the CPT manual does not specify “major” in these instances, CMS (Centers for Medicare and Medicaid Services) does, and CMS sets the standard for most payers’ guidelines. Per CMS, a major procedure is a procedure with 90 global days. And as we know, that procedure may or may not necessarily be surgical in nature.

As mentioned before, it may help to think of 57 as the 25 equivalent when it comes to getting the pre-surgery E/M paid. This is because if a major procedure is done and the preceding E/M was lacking the 57 modifier, the payer will assume the E/M was inclusive to the other services billed, and will not pay separately for it.

Important Points

  • Initial evaluation prior to a major surgery and/or procedure is always payable.
  • Modifier 57 should be appended to any E/M service on the day of or the day before said procedure when the E/M service results in the decision to go to surgery. This informs the payer that the physician determined the surgery was medically necessary.
  • Modifier 57 should only be appended to E/M codes.

Clinical Scenarios

Example 1

A surgeon sees a patient in the emergency department, then performs CPT code 65285 repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue on the same day. Since this surgical code has a 90 day global period, the correct way to bill the E/M for separate, appropriate payment is 99284-57 emergency department visit for the evaluation and management of a patient; 65285.

Example 2

An orthopedist examines their patient and discerns the need to perform non-surgical fracture care. Closed treatment of a clavicle fracture, whether CPT 23505-with manipulation, or CPT 23500-without manipulation, is not technically surgical in nature, but is a major procedure that has a 90-day global period. In this case, separate payment of an E/M service with modifier 57 is appropriate.

Example 3

A patient presents to the emergency department (ED) with abdominal pain and fever. The consulting surgeon documents a level 3 outpatient consult and decides at that visit to perform an emergency appendectomy. The appropriate coding for payment of the preceding E/M is 99243-57; 44950.

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.

Final thoughts

Separate payment of an E/M service prior to surgery by using modifier 57 is appropriate – when properly documented. Remember to use 57 when the decision was made to move forward with a major procedure in order to be compensated accordingly. Familiarizing yourself with modifiers, like 57, that are applicable for your provider and/or practice will ensure not only that the modifier is used appropriately, but that you secure the reimbursement you’re owed.

DUMMYTEXT

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