Who can use modifier 57?
Asked by: Aliyah Kemmer | Last update: August 13, 2025Score: 5/5 (55 votes)
Does Medicare recognize modifier 57?
Revision Date (Medicare): 1/1/2022
If an E&M service is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57.
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 qualify for modifier 59?
- Different session or encounter on the same date of service.
- Different procedure distinct from the first procedure.
- Different anatomic site.
- Separate incision, excision, injury or body part.
Who can bill with a GP modifier?
Used in conjunction with CPT® (Current Procedural Terminology) codes, the modifier “GP” shows that the therapy services were specifically provided by a physical therapist. This helps ensure accurate billing and reimbursement for physical therapy services under Medicare and other insurance company plans.
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Can you bill both a 25 and 57 modifier?
Both Major and Minor Surgeries on the Same Day When a decision for surgery includes both major and minor surgeries and is made the day of surgery, the E&M billed for the decision must have both modifier –57 and modifier –25 appended.
What insurance companies require the GP modifier?
The use of the GP modifier is required now on all claims to United Health Care and their affiliates, VA claims, Medicare claims, Blue Cross Blue Shield of Michigan and now Anthem Blue Cross of California.
What is modifier 57?
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 a major surgery (90 day global) or the day of a major surgery.
Under what circumstances would modifier 59 not be appropriate?
If you performed 2 procedures on different sides of the body, you may report them with modifiers LT and RT as appropriate. However, modifiers 59, XE, XS, XP, XU are inappropriate if the basis for their use is that the narrative description of the 2 codes is different.
When to use 59 or 51 modifier?
Modifier -51 would be attached because the biopsy is the lesser-valued procedure done at the same session, and modifier -59 would be attached to indicate that the biopsy, which is normally bundled with excision of the same lesion, was done on a separate lesion from the one that was excised.
What is an inappropriate use of the 57 modifier?
E/M Services Resulting in Minor Surgical Decisions
Avoid using modifier 57 for minor procedures. Insurance companies do not accept this modifier with Evaluation and Management (E/M) services where the doctor decides to perform a simple operation—surgery with a 0 or 10-day global period.
When should modifier 58 be used?
To start, modifier 58 is a surgical-specific modifier, used to indicate a staged or related procedure or service by the same physician during the postoperative period.
Can you bill an E&M with fracture care?
The option would be to not bill for the “fracture care code” and bill an E/M service on the initial encounter for the injury/fracture and for each successive encounter when the patient is seen for the fracture. The bottom line is this: E/M stands for Evaluation and Management.
What modifier is not accepted by Medicare?
GZ - Service is not covered by Medicare
The GZ modifier identifies that 1) an item or service is expected to be denied as not reasonable and necessary, and 2) no advance notice of non-coverage was supplied to the member.
What is the difference between modifier 57 and 24?
Modifier -57 would be appended for a major procedure and modifier -25 for a minor procedure (some insurance programs allow both modifiers to be appended). Modifier -24 is only used when the care provided during the global post time period is for a clearly documented unrelated visit.
What is the condition code 57 for Medicare?
Common Reason Code Corrections
Condition code 57 ( SNF Readmission) the patient previously received Medicare covered SNF care within 30 days of the current SNF admission. The 78 occurrence span code may be needed if the patient was transferred from a different SNF to your facility.
Can you use modifier 25 and 57?
APPROPRIATE USE
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.
Which scenario qualifies for modifier 58?
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.
Who can use modifier 59?
Therapists often use modifier 59 to bill for “two timed code procedures [that] are performed sequentially in the same encounter.” For instance, if you billed CPT codes 97140 (Manual Therapy) and 97530 (Therapeutic Activities)—and you provided those services during separate and distinct 15-minute intervals—then, as ...
Does Medicaid accept modifier 57?
Modifiers 24 and 57 are used with E&M codes only when the related code is a surgery service. States may implement edits that deny or reject claim lines in which a modifier is inappropriately appended to a HCPCS/CPT code (e.g., use of modifier 24, 25, or 57 with a non-E&M code).
What is the 59 modifier for mental health?
Modifier 59: This modifier signifies that service was distinct or independent from other services performed on the same day. Mental health providers might use Modifier 59 to denote separate psychotherapy sessions conducted on the same day, each addressing different issues or utilizing different techniques.
When to use modifier 55?
POSTOPERATIVE MANAGEMENT ONLY: WHEN ONE PHYSICIAN PERFORMS THE POSTOPERATIVE MANAGEMENT AND ANOTHER PHYSICIAN HAS PERFORMED THE SURGICAL PROCEDURE, THE POSTOPERATIVE COMPONENT MAY BE IDENTIFIED BY ADDING THE MODIFIER -55 TO THE USUAL PROCEDURE NUMBER OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09955.
When should a GP modifier be used?
Use a GP modifier in any case where there could be confusion as to which provider delivered services to a patient, such as in any interdisciplinary therapy setting.
Does UnitedHealthcare require GP modifier?
Effective with dates of service on or after July 1, 2020, UnitedHealthcare aligns with CMS and requires HCPCS modifiers GN, GO or GP to be reported with the codes designated by CMS as always therapy services.
What is the 59 modifier for BCBS?
Modifier 59 designates that a procedure is distinct or independent from another non -evaluation and management service performed on the same day.