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When to Use Modifier 25 and Modifier 57 on Physician Claims

October 1st, 2018 - BC Advantage
Categories:   Physicians   Modifiers   Evaluation & Management (E/M)  
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The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M.

After that, the similarities end, and it is important to know the distinctions between these two modifiers.

Modifier 25 is used to indicate that a significant, separately identifiable E/M service by the same physician or other qualified health care professional was performed on the same day of the procedure or other service. Modifier 57 is defined as decision for surgery.

From those definitions, we know that modifier 57 is intended for the encounter when it is decided that a patient requires surgery. 

Specifically, you use modifier 57 when all of the following conditions are present:

Here are some common situations when modifier 57 is misused:

Procedures with a 0- or 10-day global period can be separately reported by using modifier 25, assuming the E/M service is significant and separately identifiable. When the patient presents with the knowledge that the procedure is going to be done and no other conditions are addressed, the E/M is typically not supported and modifier 25 cannot be used.


This Week's Audit Tip Written By:  

Scott Kraft, CPC, CPMA

Scott is a Senior Compliance Auditor for our parent organization, DoctorsManagement LLC

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