Modifiers were introduced to offer better coding specificity for special circumstances that the general coding descriptors fail to capture. However, they also add a layer of complexity to the medical billing workflow.
Thus, our team of billing specialists decided to take the time to explain each modifier in detail. This blog is exclusively dedicated to modifier 57, which is used primarily with the evaluation and management (E/M) service codes.
Continue reading this guide to unveil what factors mandate its usage, when you should avoid using it, and the essential documentation requirements.
Modifier 57 – Description
Modifier 57 indicates that an E/M service resulted in the decision to perform a major surgical procedure with a 90-day global period, either the same day or the next day.
Modifier 57 – Usage Examples
Let’s take a look at a few real-world clinical scenarios that necessitate the use of modifier 57:
Emergency Department Visit Leading to Immediate Surgery
Picture a 60-year-old male patient who comes to the emergency room (ER). He complains of experiencing a sudden, severe abdominal pain accompanied by vomiting.
The attending physician performs a physical examination, orders lab tests, and a CT scan. Based on the findings, he diagnoses the patient with a ruptured appendix.
As a result, he decides to perform an emergency appendectomy (CPT 44970) immediately. The patient is taken to the operating room for a laparoscopic appendectomy with a 90-day global period.
Here, you will append the modifier 57 to the ER visit code 99285.
Inpatient Consultation Leading to Same-Day CABG
Consider a 57-year-old female patient who has been experiencing worsening unstable angina. The cardiologist visits her for an inpatient consultation. He performs a comprehensive examination and reviews the cardiac catheterization results. Based on the findings, he concludes that the patient is at a high risk of having a heart attack.
As a result, the cardiologist decides to perform an emergency coronary artery bypass graft (CABG) surgery (CPT 33533) later on the same day as the inpatient consultation encounter.
Thus, the cardiologist will report CPT code 99254 with modifier 57.
Office Visit Leading to Surgery the Next Day
Imagine a 60-year-old male patient who visits the orthopedic clinic. He complains about experiencing severe pain and limited mobility in his hip.
Thus, the orthopedic surgeon performs a detailed review of recent X-ray and MRI scans. Based on the findings, he confirms that the patient has a rapidly progressing avascular necrosis, requiring immediate attention.
As a result, the orthopedist clears the patient for surgery and schedules a total hip arthroplasty (CPT 27130) for the next morning.
Since the decision to perform surgery was taken during the office visit, you should append modifier 57 with CPT code 99214.
Accurate Usage Guidelines for Modifier 57
Master the accurate usage guidelines to avoid misuse or overuse of the modifier:
Know When You Should Append Modifier 57
Below is the criteria for billing the E/M code with 57:
For Major Procedures Only
Remember that the surgical procedure that the physician decides to perform during the E/M visit must have a 90-day global period.
The Timeframe Matters
You can only use modifier 57 if the surgery is performed on the same date of service as the E/M visit or the next day. For example, the physician conducts the E/M service on Thursday and decides to perform a total knee replacement surgery on Friday morning.
For Unbundling Purpose
Append this modifier to highlight to the payer that the E/M encounter involved a decision-making process for a surgical procedure. As a result, you expect a separate reimbursement for the E/M code.
Understand When NOT to Use Modifier 57
Avoid using it if any of the following is TRUE:
For Minor Procedures
You should not append 57 if the E/M visit led to the decision of performing a minor procedure with a 0 to 10-day global period. The reason? The decision-making process for performing minor services is typically bundled into the procedural code payment.
However, if you believe that the E/M service you rendered is distinct and separately identifiable, you should instead append modifier 25. For example, placing a cast for a new fracture.
For Scheduled Surgeries
What happens when the patient is admitted to the hospital or seen specifically by the physician for a scheduled, non-emergency surgery? In such circumstances, modifier 57 is not applicable since no ‘new decision’ was taken. Besides, for scheduled surgeries, the payment of pre-operative evaluation is included in the procedure’s global fee.
For Global Period Follow-Up
There may be scenarios where the physician renders the E/M service during the post-operative period of a previously performed surgery. If you decide to perform a new surgery during this E/M encounter, modifier 57 will not apply.
But, there are other, more specific modifiers available to help you ensure coding accuracy:
- Modifier 78: Unplanned return to the operating room for a related service during the post-operative period.
- Modifier 79: Unplanned return to the operating room for an unrelated service during the post-operative period.
Fulfill Documentation Requirements
Your documentation must include the following to support the use of modifier 57:
- Explicitly state that the procedure was unexpected. Besides, the E/M encounter served as the critical moment of high-level medical decision-making.
- The E/M notes must be properly dated and time-stamped. That is, they must support that the decision to perform the procedure was made immediately (right before the surgery or a day before).
- Explain that the surgical procedure was urgent, necessary, or emergent.
- Confirm the global period of the procedure as 90 days to support that it was a major surgery.
Final Thoughts on Modifier 57
If you do not want your high-level decision-making E/M code to go unpaid, modifier 57 is your savior.
It indicates that the E/M visit turned out to be an unexpected moment, where the physician decided to perform a major surgery on the same day or the next day. Thus, the reimbursement for the E/M code should not be bundled into the procedure’s global fee.
However, understanding just the definition of a modifier is not enough. Therefore, we took the effort to list the key criteria that mandate its usage, circumstances where you should avoid appending it, and documentation requirements.
Go through the entire guide, and hopefully it will help you avoid overusing or misusing this modifier. But, in case you need professional help, partner with a leading medical billing and coding company like NeuraBill.
FAQs
What is a modifier 57 used for?
It highlights to the payer that you made the decision to perform a major procedure during the E/M encounter.
What is the difference between modifier 57 and 25?
Modifier 25 indicates that the performed E/M service is significant, distinct from other services performed on the same date of service. Contrarily, modifier 57 is used when the physician makes a decision to perform a major procedure during the E/M visit.
Can you bill 99223 with modifier 57?
Yes, you can use 57 with CPT 99223. For context, this code covers an initial hospital inpatient or observation care visit involving high-level evaluation, management, and medical decision-making.
Can modifiers 57 and 24 be billed together?
Yes, you can append modifiers 24 and 57 together to the E/M code, but only when the E/M service is unrelated to a previously performed surgery and also results in the decision to perform a major procedure.
Does Medicaid accept modifier 57?
Medicaid guidelines vary from state to state. As a result, you must check your relevant state-specific policies before appending 57 to the E/M service code.
