Pain Management Coding Alert

Published on Mon Dec 05, 2016 PDF

Here are the answers you need to decide between these two E/M modifiers.

If your provider performs a significant, separately identifiable evaluation and management (E/M) service and a surgical procedure or other type of service on the same date, you might be able to report an E/M code along with the procedure.

Conditions: To code the E/M, you’ll have to decide whether to append modifier 57 (Decision for surgery) or 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).

For the answers you need about modifiers 57 and 25, check out this FAQ.

Q: Could you give a definition of modifier 57, for coding purposes?

You’ll use modifier 57 when the physician performs an E/M service and then decides to perform a “major” surgery during the same encounter, explains Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind. The surgery can also take place during that day or the next day when it is a major procedure carrying a 90-day global period.

The 57 modifier works just like the 25 modifier, indicating that the pre-procedure E/M is a separate and distinct service and should not be bundled into the global period for the major surgery, Holle continues.

Once the physician decides on surgery, however, the unrelated E/M service ends, says Melanie Witt, RN, CPC, MA,  an independent coding expert based in Guadalupita, N.M. “Under CPT^® rules, after the initial decision to do surgery, related E/M services are then included in the surgical code and would not be billed separately,” she reports. This would apply to E/M visits occurring the day before or the day of the surgery.

No care directly related to the performance of the procedure — such as review of history, informed consent, explaining the procedure to the patient, or informing the patient about the results and follow-up care — can be considered a separate, significant E/M service, Witt says.

Diagnosis coding myth: For claims with modifier 57, Witt says different diagnoses are not required for the E/M service and the separate procedure, but the documentation must clearly support that the E/M represents a separate, significant service.

Q: What is considered ‘major’ surgery, for coding purposes?

The global days on the procedure you code will show you if you should use modifier 57 or 25 for separate E/M services. If the procedure code has 0 or 10 globaldays, the procedure is considered “minor.” “All 90-day [global] procedure codes are major procedures,” Witt relays.

Q: So, when should I use modifier 25?

Coders should employ modifier 25 when the physician performs a significant, separately identifiable E/M service before performing a “minor” procedure, or a procedure that has a global period of 0 or 10 days, Witt explains.