Revenue Cycle Insider

Question: A Medicare beneficiary saw a provider for an evaluation and management (E/M) visit before a surgery. Would I add modifier 57 or 25 to the E/M code to report this combination of services?

Illinois Subscriber

Answer: You’ll need to gather more information, including the date of the E/M service and the date of the surgery, from the documentation or via a query before deciding on a modifier.

You’ll also need to know whether the surgery was considered minor or major surgery, which are, according to the AMA, “based solely on the common meaning of such terms when used by trained clinicians. These terms are not defined by the CPT coding’s surgical package classification.”

Additionally, the global surgery payment differs depending on whether the surgery is major or minor — and the E/M service resulting in the initial decision to perform surgery isn’t included in the major surgery global surgery payment, so the service can be billed separately.

If the surgery ends up being considered major surgery, modifier 57 (Decision for surgery) may be more appropriate than 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.).

According the Medicare Claims Processing Manual: “If evaluation and management services occur on the day of surgery, the physician bills using modifier ‘-57,’ not ‘-25.’ The ‘-57’ modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery.”

The manual specifies that appending a modifier for the E/M service might not be appropriate for a minor surgery: “Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.”

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC