What is modifier 57?
Asked by: Jermain Larson | Last update: September 29, 2025Score: 5/5 (38 votes)
When should a 57 modifier be used?
Modifier 57 should be appended to any E/M service on the day of or the day before said procedure when the E/M service results in the decision to go to surgery. This informs the payer that the physician determined the surgery was medically necessary. Modifier 57 should only be appended to E/M codes.
What is the difference between modifier 25 and 57?
Modifier 25's instructions specifically indicate that it is not to be used to report an E/M service that resulted in a decision to perform surgery. In such instances, modifier 57, Decision for Surgery, should be appended to the E/M services code.
Can I use a 24 and 57 modifier together?
You can append both modifiers 24 and 57 to E/M codes when the E/M service is either unrelated to a surgery (modifier 24) or results in the decision to perform the bundled procedure (modifier 57).
How does modifier 57 affect reimbursement?
Use modifier 57 on the E/M service—office visit, ED visit, initial hospital service, critical care service or any E/M service. Allows physician to be paid for the initial evaluation that results in surgery that day or the day before the surgery.
Modifier 57 Decision for Surgery explained medical coding
What is an example of a 57 modifier?
For example, a surgeon sees a patient and determines (and appropriately documents) that patient needs an emergency appendectomy. Because the E/M led to the decision for surgery, both the E/M (with modifier 57 appended) and the surgery may be reported, with separate payment for each.
What is a reimbursement modifier?
Modifiers provide additional information to payers to make sure your provider gets paid correctly for services rendered. If appropriate, more than one modifier may be used with a single procedure code; however, are not applicable for every category of the CPT codes.
What is the purpose of modifier 24?
Modifier 24 is defined as an unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period. Medicare defines same physician as physicians in the same group practice who are of the same specialty.
What is the 59 modifier used for?
Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.
What is the difference between major and minor surgery?
Examples of major surgery include cardiac operations, any bowel cavity operations, reconstructive surgery, deep tissue procedures, any transplant procedures, as well as any surgeries in the abdomen, chest or cranium. • Minor – Minor surgeries are generally superficial and do not require penetration of a body cavity.
What is 57 code modifier?
Modifier -57 is appended to office visits the same day or within three days of a major surgery (90-day global period). It indicates the office visit includes the decision for the major procedure.
Can you bill an office visit and a procedure on the same day?
Sometimes yes, sometimes no. The decision to perform a minor procedure is included in the payment for the procedure, unless a significant and separate E/M is needed, performed and documented.
Why is modifier 25 necessary?
The use of modifier 25 “indicates that documentation is available in the patient's record to support the reported E/M service as significant and separately identifiable,” the council report (PDF) adds.
What is the 57 modifier for NCCI?
Modifier 57 is used to indicate an evaluation and management (E/M) service resulted in the initial decision to perform surgery either the day before or the day of a major surgery (90-day global).
How do you know if a code needs a modifier?
- The service or procedure has both professional and technical components.
- More than one provider performed the service or procedure.
- More than one location was involved.
- A service or procedure was increased or reduced in comparison to what the code typically requires.
What is modifier 58 for?
Modifier 58 is defined as a staged or related procedure performed during the postoperative period of the first procedure by the same physician. A new postoperative period begins when the staged procedure is billed.
When to use modifier 90?
Independent laboratories shall use modifier 90 to identify all referred laboratory services. A claim for a referred laboratory service that does not contain the modifier 90 is returned as unprocessable if the claim can otherwise be identified as being for a referred service.
What is modifier 60 used for?
The CPT manual introduced modifier -60 in 2001 to allow providers to indicate when a procedure was more complex than normal due to an altered surgical field.
What is a 52 modifier?
Modifier -52 is used to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service.
What is a 54 modifier?
Modifier 54
When a physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding this modifier to the usual procedure code.
What is a 26 modifier?
• Modifier 26 is appended when a physician provides the professional component only of the global fee. and when the physician prepares a written interpretation and report. • Modifier 26 should only be appended to codes which are listed in the CMS NPFSRVF as modifier 26. appropriate.
What is an AM modifier?
AM. Physician, team member service. Use with code 97156 when documentation supports that a team meeting was performed. This modifier is used in addition to modifiers TG or TF based on the level of service provided.
What does CPT stand for?
Current Procedural Terminology (CPT®) codes provide a uniform nomenclature for coding medical procedures and services. Medical CPT codes are critical to streamlining reporting and increasing accuracy and efficiency, as well as for administrative purposes such as claims processing and developing guid.
What is the modifier GH?
Description. HCPCS modifier GH is used to report a diagnostic mammogram converted from screening mammogram on the same day. Guidelines and Instructions. This modifier may be submitted with CPT codes: 77065 and 77066, and HCPCS codes G0204 and G0206.