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How to Choose Between Modifiers 25 and 57

How to Choose Between Modifiers 25 and 57

When reporting an evaluation and management (E&M) service on the same claim with another service or procedure, you must append either modifier 25 “Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service,” or modifier 57, “Decision for surgery” to the E&M service code.

Modifier Identifies Separate Nature of E&M Service

A minimal patient evaluation is necessary to determine that a prescribed treatment is appropriate to manage the patient’s condition. For example, if a patient presents for a previously scheduled injection, the provider will briefly evaluate the patient to confirm that the injection remains the proper course of treatment. All billable medical procedures include this “inherent” E&M component.

Any E&M service reported must exceed the minimal evaluation and management typically included in other procedures or services billed on the same claim. A knowledgeable individual, looking at the available documentation, should be able to identify the important E&M components of history, exam, and medical decision-making (MDM), apart from any other procedures or services performed on the same day.

Identifying a significant, separately billable E&M service is easier if the provider documents the history, exam and MDM in the patient’s chart, and records the procedure note on a different sheet attached to the chart, or in a different section within the EHR (although separate documentation is not a requirement).

Note: Some E&M services may be reported using time — rather than history, exam, and MDM — if counseling or coordination of care comprise more than half of the total visit time. In such a case, you may use CPT “reference times,” along with patient status and place of service, to determine an appropriate E&M service level. See the CPT Evaluation and Management Guidelines for more information.

Modifiers 25 and 57 alert the payer, “This is not a bundled E&M service, but rather a separately billable service supported by medical necessity and clinical documentation.” If you fail to append the proper modifier, the insurer will assume the billed E&M service is incidental to other services reported, and will not pay for it…


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