ED Coding and Reimbursement Alert

Question: I have never really understood what separated modifiers 25 and 57. Could you explain the difference between them, and when I should use each?

Connecticut Subscriber

Answer: Look at the procedure's global days to determine whether you must append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other

service) or 57 (Decision for surgery) to the E/M code.

Use modifier 25 when - the ED physician provides an E/M, and then performs a minor procedure (meaning one with a 0- to 10-day global period).

For example, a patient reports to the ED with a cut on her left forearm. After performing a level-two E/M, the ED physician makes a 7.9 cm simple repair to the cut. On the claim, you would report 99282-25 (Emergency department visit for the

evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...) and 12004 (Simple repair of

superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm).

Use modifier 57 when - the ED physician provides an E/M, and then performs a major procedure (meaning one with a 90-day global period).

For example, a patient reports to the ED complaining of severe shoulder pain. During a level-four E/M, the ED physician determines the patient has a dislocated shoulder. The physician performs a shoulder reduction. On the claim, you would

report 99284-57 (- a detailed history; a detailed examination; and medical decision making of moderate complexity ...) and 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia).

If the ED physician is not providing follow-up care for the patient, remember to append modifier 54 (Surgical care only) to 23650.