Cracking the Code

Coding Modifier 57, Decision for Surgery

Modifier 57, decision for surgery, is used to indicate an Evaluation and Management (E/M) service that results in the initial decision to perform surgery either the day before a major surgery or the day of a major surgery. Modifier 57 tells the payer that they must process the claim for the E/M service instead of including it in preoperative services in the surgical package payment. To correctly append modifier 57 properly, you must remember these points: the E/M service occurs the day of or the day before a major surgical procedure which is defined as a procedure with a 90-day global period. The E/M service must prompt the surgical procedure that follows, and the E/M service must be related to the procedure that follows. Payers have different guidelines that determine reimbursement for E/M services with modifier 57, so check with individual payers for specific information.

Modifier 57 would not be appropriate under the following circumstances: appending modifier 57 to a surgical procedure code or appending to an E/M procedure code performed the same day as a minor surgery (having a 0 or 10-day post-operative period).  Applying modifier 57 would also not be applicable when the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure. Do not report modifier 57 on the day of surgery for a preplanned or prescheduled surgery or on the day of surgery if the surgical procedure indicates performance in multiple sessions or stages.

Q: True or False 99214-25,-57, 23655 is a correct code selection
A: False. Rationale: While CPT code 23655 has a 90-day global period categorizing this as a major procedure, and modifier 57 would also be appropriate as a decision for surgery, modifier 25 would be inappropriate when modifier 57 is applicable. The correct code selection here would be 99214-57, 23655. As always, we want to ensure the documentation supports the level of service.
Reference: FY 2023 CPT codebook, Appendix A, CPT assist, Novartis
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