25 or 57? Always confused about which modifier to go for? Well, read on and know the trick to pick the right modifier every time.
Your modifier 25 claims should meet all of the following criteria:
The E/M takes place on the same day as the surgical procedure
The procedure following the E/M guidelines is minor ( has a zero or 10-day global period)
The E/M service is both important and separately identificable from any inherent E/M component that the procedure involves
The same physician (or one with the same tax ID) provides the E/M service and the surgical procedure. Remember that the diagnosis associated with the E/M service can be the same as the diagnosis associated with the same-day procedure, meaning that the E/M prompted the followup procedure. Or, the diagnosis associated with the E/M service can be different than the diagnosis associated with the same-day procedure, which means that the E/M was for a significant problem unrelated to the procedure. You can go for modifier 57 if the claim meets all of the following criteria:
The E/M takes place on the same day of or the day prior to the surgical procedure
The surgical procedure following the E/M has a 90-day global period
The E/M service directly prompted the surgeon's decision to carry out surgery
The same doctor (or another doctor with the same tax ID) provided the E/M service and the surgical procedure. As modifier 57 claims involve an E/M service that ends in a decision for surgery, you'd expect to see the same diagnosis code for both the E/M as well as the surgical procedure. The surgeon wouldn't make a decision for surgery based on an important problem unrelated to the procedure. For more information on ways to pick the right modifier, sign up for a medical coding guide like Supercoder!