Urology Coding Q&A: Can you explain the difference and appropriate use of modifier -57 vs -25?

Jonathan Rubenstein, MD

Can you explain the difference and appropriate use of modifier -57 vs -25?

Although this may seem like a basic question for many coders, some do not fully understand the difference between these 2 modifiers. The definitions are as follows:

Mark Painter

Modifier -25 describes a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.Modifier -25 should be appended to an E/M service when it is necessary to indicate that the patient’s condition required a significant, separately identifiable E/M service above and beyond the preop and postop services included in a CPT code that was performed on the same date. A significant, separately identifiable E/M service must be substantiated by documentation satisfying the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). Because the reported E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided, different diagnoses are not required for reporting both the E/M and procedural services on the same date. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery; in this case, modifier -57 would be used.

In contrast, modifier -57 describes decision for surgery. This should be appended to an E/M service that resulted in the initial decision to perform surgery.

In addition to the intended differences supported by CPT definition, the modifiers are treated differently by Medicare and other payers.

Modifier -25 is intended to indicate that an E/M service was provided, and documentation supports that the service was medically necessary, significant, and separate from the procedure reported on the same date. For payers, modifier -25 represents a frequently used and abused modifier in the CPT system. Payer bundling edits and rules have been adapted to allow the reporting of modifier -25 on the same date as services and procedures with any global period if the E/M service is considered bundled as part of the global period or through bundling edits when provided on the same date of service.

Modifier -57 is only used to report an E/M service during which the decision to treat the problem with surgery is made. In addition to the day of surgery, the modifier can be used prior to the day of surgery. Although a few payers still recognize modifier -57 when used to report same-day E/M services with minor procedures, defined by Medicare as a procedure with a 0-day or 10-day global, most payers now follow Medicare guidelines. Medicare limits the use of modifier -57 in published Medicare global guidelines to the day or the day before a procedure with a 90-day global.

Both modifiers are subject to review and are increasing associated with medical record requests. As always, document well and use the modifiers when appropriate.

Send coding and reimbursement questions to Rubenstein and Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.