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Pain Management Coding Alert

Reader Question:

Use 57 when E/M Leads to 'Major' Surgery

Question: When are you supposed to report modifier 57? Is it a modifier for evaluation and management (E/M) services or procedures?

North Carolina Subscriber

Answer: When the provider performs an E/M service for a patient that leads to surgery that day (or in the near future), you'll likely append modifier 57 (Decision for surgery) to the E/M code, relays Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey. Never apply modifier 57 to a procedure code; it's for E/Ms only, and only in specific circumstances.

The 57 modifier separates patient E/M encounters from major procedures (those with 90-day global periods). You'll often use 57 during the patient's initial visit for an injury; however, you can use the modifier on an E/M "at any time during a patient's care, if the decision for major surgery is made the day of or day before the procedure," says Dawn Rogers, coding specialist at Caduceus Inc. in Jersey City, N.J.

Impact: Misuse of modifier 57 will lead to E/M denials, as payers will likely consider many preoperative E/M services part of the surgical package, Rogers warns. "This modifier tells the insurance company that a full review was performed in order to accurately assess the decision for surgery. Without the 57 modifier, the patient's visit would be considered preoperative and bundled into the procedure RVUs [relative value units]," she continues.

Remember: If the procedure is considered "minor," you might still be able to code for a separate E/M; if the provider performs a significant, separately identifiable E/M prior to a minor procedure, you'll append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M rather than 57.

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