When to Use Modifier 25 and Modifier 57 on Physician Claims

October 1st, 2018 - BC Advantage

Categories: Physicians Modifiers Evaluation & Management (E/M)

0 Votes - Sign in to vote or comment.

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)

Billing and Documenting for Therapeutic Exercises versus Therapeutic Activities
July 13th, 2022 - Dr. Evan M. Gwilliam, DC, MBA, QCC, CPC, CCPC, CPMA, CPCO, AAPC Fellow, Clinical Director

Chiropractors treat, among other things, issues with the musculoskeletal system. Active therapeutic procedures are accepted as effective ways to treat many common conditions and therefore can be billed and generate revenue for a clinic. Two common CPT codes that might be used in a chiropractic setting include:

Medicare Advantage (MA) Benchmarking Policies Are Headed for Change
July 12th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

More than 43% of Medicare beneficiaries are not enrolled in Medicare Advantage plans, which were established to control costs and improve quality. However, as noted in the March MedPac Report Executive Summary of 2021, these plans average an estimated 104% of Medicare Fee-For-Service (FFS) spending. How does CMS plan to manage Medicare Advantage plans now?

How Extensions to the COVID-19 Public Health Emergency Affect Healthcare Reimbursement
June 28th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Providers need to begin preparations for how to handle a return to pre-COVID-19 public health emergency (PHE) policies. As the saying goes, "you can't put the rabbit back in the hat." Some COVID-19 PHE policies are so well liked it will be very difficult for the government to return to pre-COVID-19 policies. For now, we have at least the promise of a 60-day notice to all governors precipitating the end of the PHE.

Why You Should Be Using The Two-Midnight Rule
June 23rd, 2022 - David M. Glaser, Esq.

Are you using something other than two-midnight? Here’s why you shouldn’t be. Is there the possibility that your utilization management team and physician advisors are applying InterQual, MCG, or any other utilization tool other than the two-midnight rule to your Medicare admissions? Over the last few months, it has...

Q/A: Service Period for 99490
June 6th, 2022 - Chris Woolstenhulme

Question: If CCM hours/work is to be billed monthly, and CCM tasks are done daily throughout the month, should it be saved until the end of the month to bill, and should each date be billed as DOS in one claim? Answer: According to CMS, “The service period for CPT 99490 ...

Reporting CCM and TCM Codes with E/M Codes
June 1st, 2022 - Chris Woolstenhulme

When reporting CCM or TCM codes, you will only get reimbursed for what is allowed. The E/M office visits can be coded in addition but are not interchangeable with CCM codes. You can bill an E/M visit during the time a patient is under Care Management, however, you can’t count time ...

Q/A: Billing Over the Allowed Amount
June 1st, 2022 - Chris Woolstenhulme

Question: Is there a financial penalty for billing over the allowed amount? Answer: Yes, if you are submitting claims to a contracted provider, you cannot bill over the contracted amount of your fee schedule. This is called balanced billing. There is also the no-surprise rule that protects insured and non-insured or ...