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Journal of Medical Practice Management


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Modifier 57
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Modifier 57 is a modifier that is appended to an E/M service to indicate that this was the visit at which the physician decided to perform surgery. It is only used on procedures with a 90 day global period, per CMS, although this is not a CPT® rule.  It is only used the day of or before a major surgical procedure.  (For a minor surgical procedure, with 0 or 10 global days, no modifier is needed the day before the service, and a 25 modifier is needed the day of the service, if the E/M service was a distinct, separate procedure.)

With the RBRVS payment system, the payment for surgeries is calculated as a global amount.  It includes the pre-work of the surgery, the intraoperative work, and the post-operative care for the number of global days assigned to the visit.  (0, 10, 90)  The number of days assigned to the visit is found in the Medicare Physician Fee Schedule Data Base.  Also included in the MPFSDB is the percentage of work for each CPT® code broken down by pre-operative care, intraoperative care and post-operative care. 

E/M services provided on the day of the day before a major surgical procedure are included as part of the pre-operative services valued in the Relative Value Units for that code.  If however, the E/M service provided the day of or the day before a major surgical procedure was the E/M service that resulted in the decision for surgery, it is separately payable.  Indicate this by appending modifier 57 to that E/M service.

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cgloomis
Tue, Sep/07/2010
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BILLER
PLEASE EXPLAIN WHAT THE DIFFERENCE OF "CPT RULE VS CMS RULE".

I AM HAVING GREAT DIFFICULTY WITH THE OFFICE MNGR WHERE I WORK. SHE INSISTS ON USING BOTH MODIFIER 25 & 57 WITH THE CONSULT CODE FOR PROCEDURES THAT HAVE 0-10 FUD.

PER YOUR ARTICLE THE CORRECT USE OF MOD 57 IS PER CMS MODIFIER 57 CAN BE USED THE DAY BEFORE OR THE DAY OF A 90 FUD PROCEDURE ACCORDING TO CMS BUT IS NOT A "CPT RULE".

THANK YOU!

The Field Guide to Physician Coding 2nd Edition
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