NGS News Modifier -25 and -57


NEWS FROM NGS

Clinical Education
December 2008
Modifier 25 vs. 57
Modifier 25 indicates a “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Modifier 25 should be used only when an E/M service performed on the same day as a minor procedure can be demonstrated through documentation to be “significant and separately identifiable.” Modifier 57 indicates the E/M service resulted in the decision to perform major surgery. Modifier 57 is then appended to the appropriate E/M code. Carriers pay for an evaluation and management service on the day of, or the day before a procedure with a 90-day global period, if the service resulted in the decision to perform the procedure. It would not be appropriate to bill evaluation and management services with, modifier 57 if the services were provided on the day before, or the day of a procedure with a 0 or 10-day global surgical period. Also modifier 57 would not be appropriate for pre-op visits. With pre-op visits, the decision for surgery has already been made. Scheduled pre-op visits the day before or day of surgery are included in the global package and should not be billed with a modifier 57. This also applies to minor procedures, those with 0 – 10 global days, and modifier 25. Preoperative care is part of the global package for major and minor procedures. Modifier 25 is used for E/M services the same day as minor procedures. Modifier 25 is a little different than Modifier 57. As mentioned earlier, Modifier 57 is used on E/M services the day before or day of major surgery when the initial decision to perform the surgery is identified. To illustrate the difference, an orthopedic surgeon visits Ms. Jones Tuesday night. It is determined that she has a hip fracture, and the surgeon decides, at that time, that an open reduction is required. The surgery is scheduled for the next morning. The E/M service is related, and not significant and separately identifiable from the major procedure performed, but since the decision for surgery was based on that E/M, it is payable with modifier 57. In the case of a clinic visit, the use of Modifier 25 would require documentation that the evaluation and management service performed was above and beyond the reason for the visit. An example: An orthopedist sees a patient with complaints of right shoulder pain and limited range of motion. The diagnosis is right frozen shoulder. The physician injects a steroid for pain relief, orders outpatient physical therapy, and prescribes an anti-inflammatory. An outpatient MRI of the right shoulder is scheduled for the next day and the physician will consider possible manual manipulation under general anesthesia. Documentation of the patient’s history, exam and decision making for the visit is completed. The physician is addressing the pain today by giving the injection. An anti-inflammatory has been prescribed and a diagnostic test to rule out other conditions ordered. This supports the management of separate issues and the use of Modifier 25.
Page last modified: 12/10/2008