Practice Management Alert

If you don't know the difference between modifiers -57 and -25, you could be causing unnecessary denials

You often deserve reimbursement when a physician renders an E/M service on the same day as, or the day before, a surgical procedure. But knowing when and how you can bill for the E/M means you need to know each procedure's global period - and the guidelines for both modifier -57 and -25.

Unlock the answers to your top questions on same-day E/M and procedure claims with these four Q&As: Question: What are the basic guidelines for when to append modifier -57 to an E/M service that leads to the decision to perform a surgery? Answer: To apply modifier -57 (Decision for surgery), the services your physician performs must meet three conditions:
  the E/M service must occur on the day of or the day before the surgical procedure,
  the E/M service must have directly led to the physician's decision to perform surgery, and
  the surgical procedure following the E/M must have a  90-day global period (that is, it must be a "major surgical procedure"). Medicare carriers "pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier -57 to indicate that the service was for the decision to perform the procedure," according to the Medicare Carriers Manual (MCM). Most third-party payers follow similar rules.

Best practice: Always append modifier -57 to the E/M service code, not the surgical procedure code, says Julia A. Appell, CPC, a coder with a general surgical practice in South Bend, Ind. Question: When does a global surgical period technically begin for billing purposes? Answer: The global surgical period for major surgeries under the Medicare fee schedule begins one day prior to the procedure itself and includes one preprocedure E/M service for patient evaluation. Therefore, payers will bundle any E/M service the physician provides on the same day as, or the day before, a major procedure.

This means that if a surgeon has already scheduled surgery, and then provides a final E/M service prior to surgery, you cannot charge separately for the service.

Example: Suppose one of your surgeons schedules cholecystectomy (47562) for a patient with a diseased gall bladder. On the day prior to surgery, the surgeon meets with the patient for a final evaluation, to answer any questions the patient has and to provide additional instructions for recovery.

In this case, you cannot charge separately for the E/M service. Because the surgeon already decided to perform surgery at a previous encounter - and because the E/M service occurs within the global period of the surgery - you should bundle this final presurgery E/M service into the cholecystectomy [...]