Primary Care Coding Alert

Question: How do I correctly assign modifier -57? It seems to be very similar to modifier -25. For example, we had a patient who came into our office complaining of a lesion that was red and irritated. Our physician decided to remove this benign lesion. Do I use modifier -57 on my evaluation and management (E/M) code or do I use modifier -25? Please give me some examples for both of these modifiers to help me clarify each.

Robin Daugherty
Indianapolis

Answer: Modifier -57 (decision for surgery) is generally used with major surgery decision-making, while modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is assigned for office procedures.

For example, a patient comes in with abdominal pain. The doctor performs an exam and discovers that her appendix is rupturing. The family physician sends the patient to the hospital, meets her there and performs the appendectomy. You would code an E/M with modifier -57 and 44960 (appendectomy; for ruptured appendix with abscess or generalized peritonitis).

The example given in the question would be coded with modifier -25. Coders would assign the appropriate E/M service with the modifier to describe the assessment of the lesion. Then they would assign a code from the 11400-11446 series for the benign lesion removal, depending on the size and location of the lesion. Modifier -25 would not be assigned if the procedure had been previously scheduled and the only purpose of the patients visit was to have the lesion removed.

You be the Coder and Reader Questions were answered by Kathy Zmuda, CPC, lead inpatient coder, Cigna Health Care of Arizona in Phoenix; and Pat Stout, CMT, CPC, an independent coding consultant in Knoxville, Tenn.