Cardiology Coding Alert

Question: There's been a debate in our office about when to correctly append modifier 25 versus modifier 57. Can you tell us more about when we should append each modifier?

North Carolina Subscriber

Answer: You should append modifier 57 (Decision for surgery) only when the surgery is major, which means it has a 90-day global surgery period.

"If the patient is having major surgery, which is a surgery that has a 90-day global surgical period, and the physician performs an E/M on the day before or day of the surgery, then use the 57 modifier," says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

Tip: Suzan Hauptman, CPC, CEMC, CEDC, AAPC Fellow, senior principal of Ace Med Group in Pittsburgh, Pennsylvania, gives a helpful way to remembering this code: Because 57 is a larger number than 25, you should use it for major procedures as opposed to minor ones.

"A/B MACs (B) may not pay for an evaluation and management service billed with the CPT^® modifier -57 if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period," according to the Medicare Claims Processing Manual30.6.6.

On the other hand, you should only append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to indicate a distinct E/M with a minor procedure (zero or 10-day global period) performed on the same day.

Remember the following rules you must also adhere when appending modifier 25:

• You can only append modifier 25 to E/M service codes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components ...) through 99499 (Unlisted evaluation and management service).
• You may use modifier 25 only when your provider's documentation proves that he performed a medically necessary and "significant, separately identifiable" E/M service in addition to the original procedure. Your physician must include a separate History, Examination, and Medical-decision making (HEM) for the E/M service in his documentation.

The E/M service must occur on the same calendar day as the original procedure, for the same patient.