March 01, 2012
Area(s) of Interest: Emergency Services Hospitals and Health Facilities Payor Issues and Reimbursement Practice Management
CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from the Director of Publishing and Warehouse for the AAPC, Brad Ericson, MPC, CPC, COSC.
Both modifier 25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, and modifier 57, Decision for surgery apply to E/M service codes only and both allow the provider to report an E/M service separately with another procedure or service. For most—not all—payers (see below), the distinction between the two modifiers depends on the nature of other, non-E/M service(s) reported.
Which do you use when?
- Modifier 57 applies when an E/M service results in the initial decision to perform a major procedure, which usually is defined as a procedure with a 90-day global surgical period.
- Modifier 25 applies when the provider performs a significant, separately identifiable E/M service on the same date as a minor procedure/service. A minor procedure/service will have a global period of fewer than 90 days (for instance, 10 days or zero days).
The concept of “major” and “minor” procedures derives not from CPT®, but from the CMS Physician Fee Schedule Relative Value File, which assigns a global period for all CPT® and HCPCS Level II codes. CPT® (Appendix A – “Modifiers”) states only that modifier 25 applies when the significant, separately-identifiable E/M service occurs on the day of a procedure or service; whereas modifier 57 applies when an E/M service results in the “initial decision to perform the surgery.” CPT® does not, however, precisely define “procedure,” “service,” or “surgery,” or assign global days for any of these categories.
For payers other than Medicare, ask for further guidance: The “major” and “minor” procedure designations apply definitively only for Medicare and those payers who follow CMS guidelines expressly. Third-party payers often follow CMS in this regard, but may designate their own rules. For example, in defiance of CMS (and CPT®) instruction, Florida Medicaid does not recognize modifier 57 and instead calls for modifier 25 anytime an E/M service and another procedure or service are reported together. The advice I give here assumes a payer who follows CMS guideline; for other payers, inquire specifically as to the rules for applying modifiers 25 and 57 and get those specific payer instructions in writing.