Modifier 57: Appropriate Use
Modifier 57: Decision for Surgery
An evaluation and management service that resulted in the initial decision to perform the surgery, may be identified by adding modifier 57 to the appropriate level of E/M service. The submission of modifier 57 appended to a procedure code indicates that documentation is available in the patient’s records which will support that the E/M service resulted in the initial decision to perform the surgery, and that these records will be provided in a timely manner for review upon request.
- Append only on E/M visits involving surgeries with a 90-day post-operative global period
- For 90-day post-operative period surgeries, global package includes day before surgery, day of surgery and 90 days after surgery
- Use when decision for surgery is made on day of or day before surgery
- Use for initial consultation or evaluation of problem by surgeon to determine need for major surgery
- Do not append to E/M visits with minor procedures (000 or 10-day post-operative period)
- Do not append to services of other physicians related to surgery, where surgeon and other physician agree on transfer of care
- Do not append to E/M service unrelated to diagnosis for which surgical procedure is performed
Major vs Minor Surgical Procedure
If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service….The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.
Procedures with a global surgery indicator of ‘XXX’ are not covered by these rules. Many of these ‘XXX’ procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This work should never be reported as a separate E&M code. Other ‘XXX’ procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure.
Additional Coding Tips
- Global period includes:
- Day before surgery
- Day of the surgery; and
- Number of days following the surgery
- Preoperative period is the day before the surgery or the day of surgery
- E/M service resulting in initial decision to perform major surgery is furnished during post-operative period of another unrelated procedure, then the E/M service must be billed with both the 24 and 57 modifiers.
Examples of Modifier 57
An orthopedist sees a patient and determines the need to provide non-surgical fracture care. Although closed treatment of a clavicle fracture, either with (23505) or without (23500) manipulation, is not a ‘surgical’ service, it does have a 90-day global period, and is therefore a major procedure for which separate payment of an E/M service with modifier 57 is appropriate, when properly documented.
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. Accurate coding would be: initial hospital visit (99221-57) and appendectomy (44950)
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 coding would be: emergency department visit (99284-57) and repair of laceration (65285)
Modifiers and CPTs © Copyright 2021 American Medical Association
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. E2E Medical Billing Services has an experienced coding team that uses exact modifiers to avoid denials. To know more about our medical billing services call us at 888-552-1290 or write to us at [email protected]