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Question: My ob-gyn decided a patient needed surgery, but I’m confused whether to report modifier 25 or modifier 57. Can you help me decide?

Montana Subscriber

Answer: It’s not unusual for coders – or providers – to sometimes mix up when to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) versus modifier 57 (Decision for surgery) on an evaluation and management (E/M) service performed during the same day as a procedure. Remember these points to help guide your decision. 

Your modifier 25 claims should meet all the following criteria:

• The original E/M service occurs on the same day or the day before the procedure.
• The procedure following the E/M is considered minor (meaning it 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) provides the E/M service and the surgical procedure.

Use modifier 57 if the claim meets all the following criteria:

• The E/M service occurs on the same day as or the day before the new procedure.
• The intended procedure following the E/M has a 90-day global period.
• The E/M service directly prompted the physician’s decision to perform the procedure.
• The same physician (or another physician with the same tax ID) provided the E/M service and the procedure.

Extra tip: 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 physician would not decide for surgery based on a significant problem unrelated to the procedure.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor