Wiki Modifier 57 vs Modifier 25

[nancy.anselmo@ccrheart.com]

I am still confussed about when to use modifier 57. Pt presented to hospital. Dr did a consult on him as he had unstable angina and CAD. During this encounter the decision was made to do a LHC. Do I use the 25 or the 57 on the 99214 pt was in observation. Thanks Nancy

 

[abbyfraise]

If the surgery was the same day you would use the 25

 

[banderson77]

depends on the post op period for the procedure. If the procedure has a 90 day global period then the office visit/consult gets a 57. All other produres (10 day or less global period) the office visit gets a 25.

 

[mad49erdog]

mod 57 use w/major surgery decision

An E&M service provided the day before or the day of a major surgery that resulted in the initial decision to perform surgery is eligible for reimbursement if modifier -57 is appended to the E&M code.

 

[Cyndi113]

It is definitely dependent on the post op days (minor vs major). However, there is no post op period for a heart cath. So in answer to your question, use a -25.

 

[kbarron]

Why aren't you using the observation codes in the observation setting?

 

[Mojo]

Why aren't you using the observation codes in the observation setting?

Since the OP's physician was a consulting provider, it appears he did not initiate the observation status and he would use office or other outpatient codes.

 

[tlspeer]

I really found the information useful. I did not know that global period had anything to do with whether a modifier-25 or -57 was used.

 

[RILEY1959]

Its a good idea to check with your payor as well. LHC's are considered diagnostic where we are and are not a surgical code so we use mod 25 on the E/M.

 

[hayleeh]

Mod 25 or 57 for er e/m codes

I have a plastic surgeon/er doc who uses e/m codes 99281-99285, he does his own coding and we audit. We're all confused which modifier to use? 25 or 57? For ex a pt came to an er with a 1.3 cm laceration of the right nostril, so the doc coded 99284 57 for the visit and 12051 for the repair. Do I change the mod 57 to 25 since it's just stitches and not a surgery? Does mod 25 need two diagnosis codes? Help!

 

[mitchellde]

you would use the 25 due to the global days being 10 or less and no you do not need more than one dx code, look in appendix A of the AMA version of the CPT book to read the complete descriptor of the 25 modifier, in that you will see where it states "separate diagnoses are not required"...

 

[anastasia213]

Do you know where I can find "official" documentation regarding the global days effecting the use of 57 vs 25?

 

[mhstrauss]

Here is a link to our Medicare carrier's modifier flowcharts:

http://www.pinnaclemedicare.com/provider/partb/education/dataanalysis/modflow/default.aspx

There is a chart for 57, but not 25, even though it references 25 in 57...go figure LOL but it may help with the documentation you're looking for.