Modifier 57 | Decision For Surgery Explained

Modifier 57 appends for the service when the physician decides on surgery in an evaluation and management setting. 

1. What is Modifier 57?

Modifier 57 is a decision for surgery modifier used to indicate that an evaluation and management (E/M) service resulted in the decision to perform surgery.

It is appended to the E/M service code when the provider decides to perform surgery on the same day or the day before the E/M service. This modifier tells the payer that the E/M service should be processed separately from the surgical package payment.

2. When to use Modifier 57?

Modifier 57 should be used when an E/M service results in the decision to perform surgery. The E/M service must be related to the following procedure and prompt the following surgical procedure. The E/M service must occur on the same day or the day before a major surgical procedure with a 90-day global period. The same provider or tax ID must provide the E/M service and the surgical procedure.

If E/M services are on the same day as a minor surgery with a 10-day global period or no global period, append modifier 25 to the E/M service, not modifier 57. Modifier 57 can also be appended to ophthalmological services 92002–92014.

3. Description

The official description of Modifier 57 is “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.

4. Examples

Examples of procedures that require modifier 57 include a patient who presents to the emergency department with acute appendicitis.

The physician performs an E/M service and decides to perform an appendectomy the same day. Therefore, modifier 57 should be appended to the E/M service code to indicate that the E/M service resulted in the decision to perform surgery.

5. Documentation

Proper documentation is essential when using modifier 57. The medical record must indicate that the E/M service resulted in the decision to perform surgery. The documentation should include the reason for the E/M service, the decision to perform surgery, and the relationship between the E/M service and the surgical procedure.

6. Billing

To bill for an E/M service with modifier 57, the E/M service code should be appended.

The surgical procedure code should be billed separately. Payers have different guidelines for reimbursement of E/M services with modifier 57, so it is essential to check with individual payers for specific information.

7. Common mistakes

Medical coders make common mistakes when using modifier 57, including appending it to the wrong code, failing to document the relationship between the E/M service and the surgical procedure, and using it for procedures with a minor surgical package. To avoid these mistakes, coders should carefully review the documentation and follow the guidelines for using modifier 57.

8. Other modifiers related to Modifier 57

Other modifiers related to modifier 57 include modifier 25, which indicates a significant, separately identifiable E/M service on the same day as a procedure or other service, and modifier 58, which indicates a staged or related procedure or service during the postoperative period.

9. Tips

When using modifier 57, it is essential to ensure the documentation supports the decision to perform surgery.

Coders should also be familiar with the guidelines for using the 57 modifier and other related modifiers to ensure proper reimbursement for services rendered.