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Usage of Modifier 25 vs 57

 Modifier 25 

Significant, separately identifiable evaluation and management [E/M] service by the same physician or Other Qualified Health Care Professional on the same day of the service 

Modifier 25 is appended to an E&M service, when performed 0 days and or 10 days global period - (never to a procedure) 

Example 1:  

A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed on same day by the same physician. 

The physician codes an E/M visit (99201 – 99215) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure. 

The modifier stops the bundling of the E/M visit into the procedure. When reviewing the physician’s documentation, the carrier should be able to determine that both the E/M and the procedure were medically necessary. As always, the documentation has to support the claim that sends to the carrier if required. 

Examples of when Not to Use Modifier 25 

Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery. 

Do not append modifier 25 if there is only an E/M service performed during the office visit (no procedure done). 

Do not use a modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed. 

Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have “inherent” E/M service included. See example #2. 

Patient came in for a scheduled procedure only – Do not code E/M service. 

Modifier 57 

Modifier 57 is an “Decision for Surgery”, Modifier 57 should only be appended to E/M codes. 

Difference between for modifier 25 vs modifier 57, 
  • Modifier 25 - Use modifier -25 on an E/M service provided on the same day as a minor procedure 
  • Modifier 57 - Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery 
Major surgery includes all surgical procedures assigned a 90-day global surgery period. 

Append, only to the E/M procedure code, where the decision to perform surgery is made the day of or day before a major surgery during an E/M service. 

Inappropriate Uses 

  • Appending to a surgical procedure code.
  • Appending to an E/M procedure code performed the same day as a minor surgery. 
  • When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure.
  • Do not report on the day of surgery for a preplanned or prescheduled surgery. 
  • Do not report on the day of surgery if the surgical procedure indicates performance in multiple sessions or stages. 

Guidelines: 

  • Global period includes, 
  • Day before surgery 
  • Day of the surgery; and 
  • Number of days following the 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 

Note: A major surgery has a 90-day post-operative period and a minor surgery has either a zero or a 10-day post-operative period. 

Example 1 

A surgeon seeing the 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 

The patient came for ED and presents with Chest Pain, Lightheadedness and palpitation on Dec 26th. And called as Cardiology consult, He is evaluated the patient and diagnosed as complete Heart Block, Coronary Artery disease. Due to the severity of the patient’s condition, the decision was made to implant Dual Chamber permanent pacemaker on tomorrow, after diagnostic testing was completed on the same date. The patient was admitted to the hospital on the same day; the claim for hospital admission was submitted with CPT code 99221 and consult document supported to bill CPT 99255. 
  • Admit – 99221 
  • Consult – 99255 - 57 
  • Pacemaker - 33208 

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