Ob-Gyn Coding Alert

There's more to -25 and -57 than separating E/M services

Pairs like modifiers -25/-57 and modifiers -52/-53 closely relate to one another by definition, but do you always know the difference between them? Selecting one over the other can boost the accuracy of your practice and stop denials in their tracks.

The following two code pairs often lead to coder confusion, but you'll find clear definitions and clinical ob-gyn examples to make choosing between them a snap. 

1. Modifier -25 Versus -57

Many coders confuse modifiers -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and -57 (Decision for surgery) because you can append both to E/M codes.

"The two modifiers are similar in concept in that you use them both to identify separate E/Ms done on the same day as a procedure," says Lisa Center, CPC, quality coordinator with Freeman Health System in Joplin, Mo. "The main difference is that you use -57 to identify that the physician made the decision for surgery (usually major) at the time of the encounter."

Modifier -25: "You should use modifier -25 when the ob-gyn provided an E/M service at the same time as a procedure in your office," says Peggy Stilley, CPC, office manager for Women's Healthcare Specialists, an Oklahoma University-based ob-gyn practice in Tulsa.

Appropriately appending modifier -25 means that your practice will receive a separate payment for an E/M service that the ob-gyn performed on the same day as a procedure or other service.

"This is probably the most important of all the modifiers," says Jean Ryan-Niemackl, LPN, CPC, an application specialist with QuadraMed Government Programs in Fargo, N.D. "You should always use this modifier on E/M codes and never on procedure codes."

For example: The ob-gyn sees a patient with vaginal bleeding. During the exam, the ob-gyn identifies polyps in the cervical os and decides to remove the polyps today instead of requesting the patient to return.

You would report the visit code (9921x) with modifier -25 appended in addition to 57500 (Biopsy, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]), Stilley says.

Modifier -57: You should only use modifier -57 when the ob-gyn determines that he needs to perform a major surgical procedure (one with a 90-day global period) and will perform it either that same day or the next day.

"Most carriers only want this applied if the decision is made with the global pre-op period, but this doesn't always apply," Ryan-Niemackl says.

Keep in mind that you should particularly use modifier -57 for Medicare patients because one day prior to surgery, a major surgery's preoperative period begins.

For example: the ob-gyn examines a patient for menorrhagia and anemia and discusses options with the patient. During this visit, the ob-gyn decides to proceed with a hysterectomy. You would report the visit code (9921x) with modifier -57.

The rule: You should report both the E/M service and the procedure if the ob-gyn decides to perform the procedure at the same encounter as the E/M service, regardless of the diagnosis.

"Typically, you would use modifier -57 on major surgeries (those with a 90-day global) and use -25 on minor procedures (0- and 10-day globals)," Center says.

You may also report both the E/M service and the  procedure code as long as both have different diagnoses (append modifier -25 to the E/M code with a minor procedure, or modifier -57 for a major procedure).

2. Modifier -52 Versus -53

Modifiers -52 (Reduced services) and -53 (Discontinued procedure) both describe halted procedures, but they differ in that "you use -52 when your ob-gyn performs a reduced service or has not completed all of the components of the code description, and modifier -53 when the patient's well-being is in question," Stilley says. 

Modifier -52: You should use modifier -52 for a failed procedure when the ob-gyn could not complete the originally planned surgery. "The physician elects to reduce or eliminate a portion of a service or procedure," Center says.

For example, the ob-gyn attempts to perform an endocervical curettage (57505, Endocervical curettage [not done as part of a dilation and curettage]), but cervical stenosis prevents him from completing the procedure. You would report 57505-52.

"Sending a cover letter and op note may be helpful in providing the payer with an explanation how the reduced fee reflects the reduction or elimination of a portion of the service," Center says.

Modifier -53: In contrast, you should use modifier -53 only when the surgeon stops the entire procedure and takes the patient to recovery because of her condition. "No other procedure is done," Stilley says.

"This modifier can only be used if the procedure was discontinued after anesthesia was administered and/or the patient was prepped in the operating suite," Center says.

For example, the ob-gyn attempts to perform the same endocervical curettage, 57505. This time, the patient under anesthesia experiences a heart arrhythmia, and the ob-gyn decides not to continue the procedure.

You should report 57505-53 to show that the physician discontinued the surgery because of the patient's condition.

Heads up: Don't confuse modifiers -52 and -53 with modifiers -73 (Discontinued outpatient procedure prior to anesthesia administration) and -74 (Discontinued outpatient procedure after anesthesia administration). Generally, only hospitals or ambulatory surgery centers use modifiers -73 or -74 for services and procedures performed for outpatients.