Coding

Modifiers 25 and 57: Appropriate use

When to use or avoid these often misunderstood modifiers.

BY PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA

Modifiers 25 and 57 are office-based CPT modifiers; they apply to claims when an office visit and surgery happen in close proximity to one another (the same day or following day). They are often confused with one another but differ in significant ways.

Knowing the circumstances when they might apply is crucial to understanding their appropriate use. Additionally, modifier 25 has been placed on the Office of the Inspector General’s (OIG) Annual Work Plan for the past few years, so it is getting increased scrutiny.

Modifier 57

This modifier is the easiest to understand. Modifier 57 is only used when a major surgery is planned. Although CPT does not specify, Medicare considers modifier 57 to apply to the office visit when deciding to perform a major surgery, and nearly all payers agree. In this case, “major” or “minor” is defined solely by the payer’s global period designation. Major surgeries generally have a 90-day post-operative period, although in some rare state Medicaid programs some eye surgeries with a 30-day period and would still be considered “major” surgery.

Example 1: A patient presents for an office visit with increasing flashes and floaters in the right eye for the past few days. On exam, you discover a retinal tear and immediate laser surgery is indicated. If the laser surgery (all retina lasers carry the designated 90-day post-operative global period) is scheduled today or tomorrow, append modifier 57 to the office visit code to show that you decided on the major surgery at this visit. Modifier 57 informs the payer that payment for the exam on this day is proper in addition to the laser code, which you file as usual. Leaving off modifier 57 tells the payer that you did not decide on that day; they will bundle the exam and pay only for the laser.

Example 2: You indicate cataract surgery at the exam. Since you don’t plan to schedule surgery that day or the next, modifier 57 is not required for payment purposes; the global period is not implicated here. Major surgery includes both the 90 days post-operatively and the “day of” and “day before” the major surgery. If you used modifier 57 here to show that the decision for cataract surgery was made, it won’t cause a rejection — and payment based on the level of exam filed should encounter no other problems.

Modifier 25

This one is a bit more challenging. CPT notes the following (my emphasis in bold): “It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identified E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.” CPT also states: “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting the E/M service on the same date. … Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57.” Note the distinction between modifier 25 and 57, which is the most common area of confusion.

Example 1: Your patient presents with an eyelash irritating each upper lid: the eyelash on the right upper eyelid is epilated, and the eyelash on the left upper eyelid can be moved back into proper position at the slit-lamp. The exam and the minor procedure carry the same diagnosis (i.e., trichiasis). In this case, use modifier 25 for the examination of the left upper eyelid. The right upper lid exam and subsequent epilation are part of the minor procedure and are not billable. The level of billed exam for the left eye is based solely on the elements for that eye and lid.

Example 2: Your patient has wet AMD in the left eye that you have followed for quite a while. The right eye has mild, dry AMD, which has not progressed and was evaluated recently. At the last OS injection one month ago, your chart note stated “evaluate for possible injection for exudative AMD, OS in 1 month, OD stable and unchanged.” At presentation for the injection today, no symptoms or visual changes related to the right eye are noted in the chart. The injection is performed OS although the chart documents that the provider looked at each eye’s retinas. Modifier 25 use here is improper: the exam of the left eye is pre-operative, and the payer will see no reason for an examination of the right eye this soon after the most recent one.

Conclusion

You must know proper and improper uses of these common office-based modifiers. Failure to do so has significant compliance and payment concerns. OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.