Podiatry Coding & Billing Alert

Question: I'm confused about the distinction between modifiers 25 and 57. Could you please explain the difference?

Ohio Subscriber

Answer: You might use either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) when your surgeon performs a procedure and a distinct E/M service for the same patient on the same day. The quickest distinction is that you would use 25 for a distinct E/M with a minor procedure, and 57 for a distinct E/M with a major follow-up procedure. Read on for a more nuanced description of how you should use the two modifiers.

Do this for 25: Your modifier 25 claims should meet all of the following criteria:

• The E/M occurs on the same day as the surgical procedure
• The procedure following the E/M is minor (has a zero- or 10-day global period)
• The E/M service is both significant and separately identifiable from any inherent E/M component that the procedure involves
• The same physician (or one with the same tax ID, same specialty) provides the E/M service and the subsequent procedure.

Note that the diagnosis associated with the E/M service can be the same as the diagnosis associated with the same day procedure, which means that the E/M prompted the follow-up procedure. Or, the diagnosis associated with the E/M service can be different than the diagnosis associated with the sameday procedure, meaning that the E/M was for a significant problem unrelated to the procedure.

Follow 57 guidelines: Use modifier 57 if the claim meets all of the following criteria:

• The E/M occurs on the same day of or the day before the surgical procedure. Note: Technically, this is an informative modifier and should be used whenever the decision is made. As a rule of thumb, to be safe many experts instruct providers to use 57 if surgery is planned in the next 7 days.
• The E/M service directly prompted the surgeon's decision to perform surgery
• The surgical procedure following the E/M has a 90- day global period
• The same surgeon (or another surgeon of the same specialty with the same tax ID) provided the E/M service and the surgical procedure.

Because modifier 57 claims involve an E/M service that results in a decision for surgery, you would expect to see the same diagnosis code for both the E/M and the surgical procedure. The surgeon would not make a decision for surgery based on a significant problem unrelated to the procedure.