ED Coding and Reimbursement Alert

Your modifier 25 claims should meet all of the following criteria:

• The E/M occurs on the same day as the procedure
• The procedure following the E/M is minor (has a zero- or 10-day global period)
• The E/M service is both significant and separately identifiable from any inherent preoperative E/M component that the procedure requires
• The same physician (or one with the same tax ID) provides the E/M service and the surgical procedure.

Note that the diagnosis associated with the E/M service can be the same as the diagnosis associated with the same-day procedure. Or the diagnosis associated with the E/M service can be different than the diagnosis associated with the same-day procedure, meaning that the E/M may be for a significant problem unrelated to the procedure.

Use modifier 57 if the claim meets all of the following criteria:

• The E/M occurs on the same day of or the day before the surgical procedure
• The surgical procedure following the E/M has a 90-day global period
• The E/M service directly led to the physician’s decision to perform surgery
• The same physician (or another physician with the same tax ID) provided the E/M service and the surgical procedure.

Because modifier 57 claims involve an E/M service that results in a decision for surgery, you would expect to see the same diagnosis code for both the E/M and the surgical procedure. The provider would not make a decision for surgery based on a significant problem unrelated to the procedure.