Revisiting Modifiers 25 and 57

If you have a number of medical billing claims getting rejected, once you rule out any larger reasons, you might start looking for the key in the use of; or rather the lack of not using modifiers as a part of your medical billing claims.

Two of the main modifiers that get people in trouble with their medical billing claims in the forms of rejections are modifiers 25 and 57. Modifier 25 reads , “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service” is kind of a catch all modifier for procedures that may not have an exact coding you can assign.

Previously, modifier 25 was easily confused with modifier 57 and 57 was then updated in 2006 to reflect the following wording, ” Decision for Surgery”. It’s easy to determine if you need to use modifier 57, simply check the notes and determine if there was a decision for surgery – is yes then use 57 as part of your medical billing claim. If there was no such decision made on your medical billing claim, be sure not to use that particular modifier.

Another way to almost completely eliminate errors and omissions in your medical billing claims is to outsource your medical billing claims and let the pros that make it their job keep up with the lightening fast changes in the medical billing industry and leave you with the time to help your practice grow even more successful.

View all Articles by: Kathryn Etienne, CCS-P