Use modifier 57 for decision for surgery on hospitalized patients

Why This Topic Matters

Correct modifier selection affects whether the E/M service is separately reported or bundled, which can influence claim accuracy and reimbursement. The article is useful for avoiding common coding mistakes when surgery is decided during a hospital stay or during evaluation preceding a minor procedure.

Article Sections

1. Decision for surgery in hospital and observation settings

   Scenarios are presented for inpatient and observation encounters where an E/M service occurs around the time a major procedure is scheduled. The section focuses on timing considerations in relation to the hospital stay and surgery date.

2. Use modifier 25 on E/M with minor procedure

   This section compares modifier 25 with modifier 57 in the context of same-day E/M services and minor procedures. It also discusses documentation concepts and a cystourethroscopy/biopsy example.

3. No modifier 57 for pre-op exam

   The article distinguishes routine preoperative clearance from an encounter that establishes a surgical decision. It notes how this differs from reportable decision-for-surgery situations.

4. Global periods are Medicare, not CPT

   This section explains that global period concepts are tied to payment policy and may vary by payer. It also addresses the relationship between Medicare guidance, CPT nomenclature, and private payer review.