When to Use Modifier 25 and Modifier 57 on Physician Claims
October 1st, 2018 - BC Advantage
The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M.
After that, the similarities end, and it is important to know the distinctions between these two modifiers.
Modifier 25 is used to indicate that a significant, separately identifiable E/M service by the same physician or other qualified health care professional was performed on the same day of the procedure or other service. Modifier 57 is defined as decision for surgery.
From those definitions, we know that modifier 57 is intended for the encounter when it is decided that a patient requires surgery.
Specifically, you use modifier 57 when all of the following conditions are present:
- During the encounter, the physician or other provider decides that a major surgery needs to be done, and that surgery is done either on the same date of service or the next calendar day.
- The surgery is a major surgery, meaning one with a 90-day global period.
Here are some common situations when modifier 57 is misused:
- A surgical decision is made, but the physician continues to round with the patient daily until the surgery can be scheduled/completed. The surgeon should not append modifier 57 to the last E/M prior to the surgery as the decision for surgery is not being made - it has been made. In most instances, this same day E/M is bundled into the surgery. If other problems are addressed, modifier 25 may be indicated.
- A procedure that has a 0- or 10-day global period.
Procedures with a 0- or 10-day global period can be separately reported by using modifier 25, assuming the E/M service is significant and separately identifiable. When the patient presents with the knowledge that the procedure is going to be done and no other conditions are addressed, the E/M is typically not supported and modifier 25 cannot be used.
This Week's Audit Tip Written By:
Scott Kraft, CPC, CPMA
Scott is a Senior Compliance Auditor for our parent organization, DoctorsManagement LLC
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)
Reporting Modifiers 76 and 77 with ConfidenceApril 18th, 2023 - Aimee WilcoxModifiers are used to indicate that a procedure has been altered by a specific circumstance, so you can imagine how often modifiers are reported when billing medical services. There are modifiers that should only be applied to Evaluation and Management (E/M) service codes and modifiers used only with procedure codes. Modifiers 76 and 77 are used to identify times when either the same provider or a different provider repeated the same service on the same day and misapplication of these modifiers can result in claim denials.
Five Documentation Habits Providers Can Use Implement to Improve Evaluation & Management (E/M) ScoringApril 11th, 2023 - Aimee WilcoxProvider education on E/M coding updates is vital to the success of any organization, but how do you whittle down the massive information into bite-sized pieces the providers can learn in just a few minutes? Check out the five steps we have identified to teach providers in just a few minutes that can significantly impact and improve coding outcomes.
Second Quarter 2023 Updates are Different This YearApril 6th, 2023 - Wyn StaheliThe second quarter of 2023 is NOT business as usual so it is important to pay attention to ensure that organizational processes and training take place to avoid mistakes. Not only have ICD-10-CM coding updates been added to the usual code set updates (e.g., CPT, HCPCS, ICD-10-PCS), but the end of the COVID-19 Public Health Emergency will bring about changes that will also take place during the quarter (but not on April 1, 2023.
7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth FraudMarch 28th, 2023 - Aimee WilcoxA recent review of telehealth services reported in Medicare claims data during the pandemic where these seven measures for identifying suspected fraud, waste, and abuse were applied, revealed more than a thousand Medicare providers potentially committed fraud during this period. What are the measures the OIG applied during their review, and how will that impact future telehealth guidelines moving forward?
MUEs and Bilateral IndicatorsMarch 23rd, 2023 - Chris WoolstenhulmeMUEs are used by Medicare to help reduce improper payments for Part B claims. This article will address the use of the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) and how they are used by CMS.
It is True the COVID-19 PHE is ExpiringMarch 16th, 2023 - Raquel ShumwayThe COVID-19 PHE is Expiring, according to HHS. What is changing and what is staying the same? Make sure you understand how it will affect your practice and your patients.
Billing Process FlowchartMarch 2nd, 2023 - The Billing Process Flowchart (see Figure 1.1) helps outline the decision process for maintaining an effective billing process. This is only a suggested work plan and is used for demonstration purposes to illustrate areas which may need more attention in your practice’s policies and...
