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.