Modifier 57

Decision for Surgery: An evaluation and management (E/M) service that resulted in the initial decision to perform the surgery may be identified by adding this modifier to the appropriate level of E/M service.

Correct Use

  • Append only on E/M visits involving surgeries with a 90-day post-operative global period
    • For 90-day post-operative period surgeries, global package includes day before surgery, day of surgery and 90 days after surgery
  • Use when decision for surgery is made on day of or day before surgery
  • Use for initial consultation or evaluation of problem by surgeon to determine need for major surgery

Incorrect Use

  • Do not append to E/M visits with minor procedures (000 or 10-day post-operative period)
  • Do not append to services of other physicians related to surgery, where surgeon and other physician agree on transfer of care
  • Do not append to E/M service unrelated to diagnosis for which surgical procedure is performed

Claim Example

A 70-year-old patient presents to an emergency room (E/R) with acute abdominal pain right lower quadrant. After a detailed history and exam, the decision is made to take the patient immediately to the OR for an appendectomy.

Date of Service Treatment CPT/Modifier
05/23/17 Initial Hospital Visit 99221-57
05/23/17 Appendectomy 44950

 

Use of this modifier will allow separate reimbursement for the surgeon's visit on the day of surgery. It will not be a part of the global surgical package when reported with the modifier 57. If the decision for surgery was made a week prior, no modifier should be used and the visit on the day before or day of surgery is included in the global surgical package and no extra allowance is given.

 

Last Updated Tue, 23 Oct 2018 15:24:11 +0000