Wiki Modifier 25 & 57 usage on same E/M

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sathyaraj

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Dear friends
I am not able to see any guidelines for the coding of 25&57 modifier coding together in a single E/M, is it possible to append 25&57 modifier both in the initial hospital visit(99221-99223) for a major(90days GP), minor(90days GP) procedure is performed in same day?
 
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sathyaraj said:
Dear friends
I am not able to see any guidelines for the coding of 25&57 modifier coding together in a single E/M, is it possible to append 25&57 modifier both in the initial hospital visit(99221-99223) for a major(90days GP), minor(90days GP) procedure is performed in same day?
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If the patient had 2 procedures, each with a 90 day global period, on the same date, you would only need to use modifier 57. A major procedure is considered a procedure with a 90 day global, where a minor procedure would have 0-10 day global - and if that is done on the same date as the E/M, you would assign a 25 modifier. Otherwise, if the decision to do major surgery that day or the next day was made during the E/M, then you would use the 57.
 
I happened to come across this and thought it might be helpful:

CMS Manual System
Department of Health &Human Services (DHHS)
Pub 100-04 Medicare Claims Processing
Centers for Medicare & Medicaid Services (CMS)
Transmittal 2997
Date: July 25, 2014
Change Request 8688


4. Evaluation and Management Service Resulting in the Initial Decision to Perform Surgery
Evaluation and management services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately.
In addition to the CPT evaluation and management code, modifier ?-57? (decision for surgery) is used to identify a visit which results in the initial decision to perform surgery. (Modifier ?-QI? was used for dates of service prior to January 1, 1994.)
If evaluation and management services occur on the day of surgery, the physician bills using modifier ?-57,? not ?-25.? The ?-57? modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.

The source url is https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2997CP.pdf
 
What about if it was decision for a major procedure which needs the -57, but pt also had testing (echo, ekg, etc) done earlier that day as well? The reason for testing is not listed as preop, and could have been hours before the decision was made for surgery. At that point, would it be appropriate to also append a -25 along with the -57 to the E&M level code?
 
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