How to Choose Between Modifiers 25 and 57

When reporting an evaluation and management (E&M) service on the same claim with another service or procedure, you must append either 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," or modifier 57, "Decision for surgery" to the E&M service code.

Modifier Identifies Separate Nature of E&M Service

A minimal patient evaluation is necessary to determine that a prescribed treatment is appropriate to manage the patient's condition. For example, if a patient presents for a previously scheduled injection, the provider will briefly evaluate the patient to confirm that the injection remains the proper course of treatment. All billable medical procedures include this "inherent" E&M component.

Any E&M service reported must exceed the minimal evaluation and management typically included in other procedures or services billed on the same claim. A knowledgeable individual, looking at the available documentation, should be able to identify the important E&M components of history, exam, and medical decision-making (MDM), apart from any other procedures or services performed on the same day.

Identifying a significant, separately billable E&M service is easier if the provider documents the history, exam and MDM in the patient's chart, and records the procedure note on a different sheet attached to the chart, or in a different section within the EHR (although separate documentation is not a requirement).

Note: Some E&M services may be reported using time - rather than history, exam, and MDM - if counseling or coordination of care comprise more than half of the total visit time. In such a case, you may use CPT "reference times," along with patient status and place of service, to determine an appropriate E&M service level. See the CPT Evaluation and Management Guidelines for more information.

Modifiers 25 and 57 alert the payer, "This is not a bundled E&M service, but rather a separately billable service supported by medical necessity and clinical documentation." If you fail to append the proper modifier, the insurer will assume the billed E&M service is incidental to other services reported, and will not pay for it.

Supporting a Separate E&M Service

Typically, medical necessity and clinical documentation will support a separately billable E&M service when the patient presents with a new problem that requires evaluation and treatment. Or, the patient presents with an established problem that has worsened and requires further evaluation and a change in treatment plan. When an E&M service leads to an unplanned, same-day procedure, documentation must establish that the decision to perform procedure was made during the encounter.

Each CPT code reported must be linked to a diagnosis substantiated in the medical record. CMS Transmittal R954CP establishes that an E&M service "may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E&M services on the same date."

Global Period Determines Correct E&M Modifier

CMS and nearly all private payers classify non-E&M procedures as either "major" or "minor." This information is crucial to determine whether modifier 25 or modifier 57 is appropriate to append to the E&M service code reported.

Major procedures have a 90-day global period. All other procedures (e.g., those with a zero-day, 10-day, or other assigned global period) are minor procedures. You can find a global period look-up tool on the CMS website: cms.gov/apps/physician-fee-schedule/overview.aspx.

Append Modifier 25 for Minor Procedures

If the provider furnishes a minor procedure and a separate E&M on the same date of service (at the same or a separate encounter), append modifier 25 to the E&M service code. Examples of minor procedures include many injections, minor integumentary repairs, and endoscopic procedures (e.g., diagnostic colonoscopy).

You normally will not report a separate, same-day E&M service if the provider sees a patient for a previously scheduled procedure or service. Per the Medicare Claims Processing Manual (Chapter 12, Section 40.1), "Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed."

Turn to 57 for Major Procedures

Append modifier 57 to a separately identifiable E&M service that occurs on either the same day or the day before, a major surgical procedure, and that results in the decision to perform the surgery, per Medicare's Claims Processing Manual, section 40.2.

CPT guidelines do not allow separate payment for a E&M service to clear a patient for surgery, after the decision for surgery has been made, stating, "Evaluation and management services subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)" are "included in addition to the operation per se."