Modifier 57 appends for the service when the physician decides on surgery in an evaluation and management setting.
Modifier 57 Description
Modifier 57 applies with the services when the physician provides the evaluation and management service that ensued in the initial decision to perform the surgery by adding modifier 57 to the appropriate level of E/M visit.
Modifiers 57 and 25 may use for similar purposes. Still, the main difference is that modifier 57 may use for major procedures, and 25 is adequate for minor procedures. Mostly, modifier 25 applicable when the patient receives a trigger injection, resulting in an E/M visit.
For Instance, if the patient saw by the provider for osteoarthritis, they may receive an injection during the same encounter. While the patient solely presents for trigger injection, it is inappropriate to report the E/M service or check the payer guidelines if adequate. It is reasonable to bill with modifier 25.
Modifier 57 is inappropriate when service provides to the patient during a preoperative visit (when the physician has already decided on surgery), and the purpose is to know the patient’s current status before the surgery.
Modifier 57 indicates when submitting to the insurance that all additional documents are available for the E/M service, leading to the decision in the surgery for reimbursement. Documentation must represent the circumstances of services and statements that make the service medically necessary and appropriate.
Modifier 57 may apply to the primary surgical and the other significant procedures, which have a 90-day global period. The word “major” means that it can be a surgical or other procedure and not confined to the surgical only.
The global period which has 10 or 90 days, includes the day of minor and major procedures, the day before the surgery when the 90-day global period, and the number of days in the postoperative period. Major surgeries have 90 days in the postoperative period, while minor surgeries have zero or ten days.
CMS defines the major procedure with a 90-day global period, and other services which are not surgical have 90 days global period. If modifier 57 does not append to the service, the payer may assume that service is inclusive in another major procedure and leads to no reimbursement.
It is appropriate to report modifier 57 along with modifier 24 when the decision makes by the physician to perform the major procedure in the postoperative period.
What Is Modifier 57?
Modifier 57 represents the evaluation and management service when a physician decides on the day of surgery or one day before the surgery, which has 90 days global period. It is only appropriate to report with evaluation and management service.
When To Use Modifier 57
The following are the uses of modifier 57 when applicable:
It is only valid when the physician performs evaluation and management service before the effective surgical procedure or may attach to the service on the day of surgery for evaluation and management service on the same decision for the surgery.
The E/M service should result in the decision to perform the surgical procedure on the patient. The insurance or third-party payer may reimburse this visit if medically necessary and appropriate.
For Instance, the physician sees the patient in the morning for acute abdominal pain. They recommend a laparoscopic appendectomy (which has a 90-day global period). This encounter results in the decision to the surgery on that day or by tomorrow and appropriate document in the evaluation and management setting, which is separately payable.
It may also apply to the non-surgical procedure, which has a 90-day global period. In this case, The physician sees the patient with a clavicle fracture. They perform the closed treatment of clavicle procedures with or without manipulation (23500 or 23505), which are not surgical procedures but have 90 days global period.
It is appropriate to report these services with modifier 57 when adequately documented in the evaluation and management visit.
Modifier 57 Guidelines
The following are the guidelines when modifier 57 is appropriate with CPT codes:
Modifier 57 is inappropriate to append with surgical procedure codes ranging from 10000-60000. It is also not applicable to radiological procedure codes, medicine sections, anesthesia procedures, and laboratory and pathology CPT codes. It is appropriate to report radiological procedures with modifiers 52, 53, 77, 76, etc.
Modifier 57 is inappropriate to attach to the service when the physician performs minor surgery in addition to E/M service (99201-99499). The physician decides to perform a minor procedure immediately after E/M service. It may consider a routine procedure combined with minor surgery and not separately payable.
Modifier 57 is not applicable for preplanned or prescheduled procedures on surgery day. It may also be inappropriate to report when the same physician performs a process in multiple sessions or stages.
Modifier 57 is not applicable when the physician does not decide on the surgery on a later day in an evaluation and management (99202-99499) visit.
Modifier 57 is inappropriate to attach with the service when the physician performs the critical care services. For Instance, the patient presented to the ED department with massive bleeding due to an automobile accident and had an abdominal injury.
The patient’s condition became critical, and she sends to the ICU for 80 minutes-the patient’s condition was stable, and they needed an immediate laparotomy of the abdominal region. It is inappropriate to report 57 for the ICU visit.
The insurance may deny the procedure or service unbundle with modifier 25 to indicate separately identifiable service. It may consider part of a major surgical procedure and may not be reimbursable when performed by the same physician. For Instance, a Physician sees a patient with shoulder pain in the morning and returns to the provider for an abdominal procedure. It is appropriate to report the E/M visit with modifier 25.
Similarly, suppose the same patients present to a physician with acute abdominal pain in the morning and decide to do the laparotomy procedure of the abdomen later in the day. In that case, it is appropriate to report the evaluation and management visit with modifier 57 instead modifier 25.
Modifier 57 Examples
The following are the examples of modifier 57 when applicable:
A 47-year-old female presented to the emergency department with complaints of epigastric pain, nausea, vomiting, and diarrhea since this morning.
The patient states that she woke up with symptoms and has had many episodes of bilious vomiting and bloody watery diarrhea since this morning. She says that she had never faced any problem previously. Denies numbness, tingling, headache, or itching.
The physician performed diagnostic studies to reveal the problem and ordered medications like IV fluids, Pepcid, Toradol, and Zofran to treat diarrhea and pain. The pain was getting worse after the pills.
Physical exam revealed that differential dx are appendicitis, gastritis, colitis, diverticulitis, and gall stones.CPT and MRI of the abdomen show abnormal findings.
The studies show that the gallbladder fills with stones and needs immediate removal from the body. It may threaten the patient’s life if the procedure does not perform immediately. The physician performs the appendectomy (47562) on the same day as the E/M visit serves.
CPT 47562 has 90 days global period, and it is appropriate to report modifier 57 with an E/M visit for reimbursement.
A twenty-year-old male presents to the office with the condition of severe headache and nausea. He had approximately eight episodes of non-bloody vomiting, around three episodes of non-bloody diarrhea, and extreme body aches since this morning.
He also had a family history of colon cancer and denies fever, chills, urinary complaints, chest pain, cough, back pain, or recent travel. He denies any weight changes and has no jaundice. Patient conditions were not better by giving medications, and pain became worse in the upper abdominal region. The patient was not capable of eating or drinking anything.
The patient had a malformation in the prior Colostomy. The physician decided to repair the Colostomy by tomorrow. CPT 44620 reports for this service which has 90 days global period and bundle with an E/M visit. It is appropriate to report with modifier 57 with the E/M visit.
A Thirty-year-old male with no past medical history now presents with severe pain in the right lower quadrant. The pain started two days ago and got worse with movement. The patient did not take any medication for pain.
The patient denies headache, blurry vision, itching, dryness, dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, nausea/vomiting, and urinary bladder issues.
Physicians order diagnostic services such as CT and MRI of the abdomen and pelvis region. Diagnostic studies revealed that the patient has acute appendicitis. The patient’s condition is getting worse, and has the possibility of appendix rupture or spreading infections to the other organs.
The physician consulted with Gastrentrologyst for further proceedings and suggested immediately removing the appendix from the body. He schedules an appointment for an appendectomy by tomorrow.
CPT code 44970 (laparoscopic appendectomy) performs by the physician. It has 90 days global period, and it is appropriate to report with modifier 57.