Pediatric Coding Alert

Question: I noticed modifier 57 in CPT Appendix A. As a general pediatrician, I have rarely used this modifier. Should I use it more often?


Iowa Subscriber

Answer: Modifier 57 (Decision for surgery) doesn't usually apply to general pediatric situations. When a physician performs an E/M service in which he makes the decision for same-day surgery, he should append modifier 57 to the E/M code (such as 99251-99255, Initial inpatient consultation for a new or established patient ...).

Many insurers follow Medicare's policy and expect modifier 57 only on claims containing major surgeries. So if a pediatrician performs only minor surgeries - those containing global periods of less than 90 days - you wouldn't have a reason to use modifier 57. A pediatric specialist would, however, find the modifier more appropriate for 90-day global procedures.