Modifier Coding Alert

Question: During an E/M of an established patient, my physician made the decision to use a local anesthesia on an area of the tongue to be biopsied. She made an incision in the area to be biopsied and removed a portion of the lesion and some surrounding tissue (41100) in the affected area of the tongue (anterior one–third). She then performed a simple closure. Wouldn’t I need a modifier for this claim?

Arkansas Subscriber

Answer: You would need modifier 57 (Decision for surgery) attached to the 41100 (Biopsy of tongue; anterior two-thirds). You’ll use modifier 57 because the evaluation and management service resulted in the decision to perform the surgery.

Be mindful that you don’t confuse 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) and modifier 57. The primary difference between modifiers 57 and 25 is that you’ll use modifier 57 when the E/M service resulted in the decision for the major surgery. You’ll use modifier 25 when there’s a separate identifiable E/M service on the same day of a minor surgery or procedure.