ED Coding & Reimbursement Alert - 2014 Issue 3
Mind Your Modifiers: Save Time By Understanding When to Use Modifier 57
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Article Overview
This article discusses payer scrutiny of modifier 57 and the kinds of denial issues that can arise when an evaluation and management service is linked to a surgical decision. It focuses on broad billing and claim-editing considerations, including differences in payer global-period definitions, potential software-related bundling issues, and practical steps to verify payer expectations. The article is relevant for coding professionals, billing staff, and compliance teams who need to understand how payer policy differences can affect claim processing and appeals.
Why This Topic Matters
Understanding the payer-specific handling of modifier 57 can help practices reduce unnecessary denials, avoid unproductive appeals, and better align billing workflows with contract requirements and reimbursement expectations.
Article Sections
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Know Your Payer’s Definition of a Global Period
Explains that payer interpretations of global surgical periods can differ and may affect whether claims are processed separately. The section emphasizes the importance of knowing payer-specific rules and maintaining reference information for billing use.
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Be Aware of Possible Problems with Payer’s Claims-Editing Software
Describes how claim denials may occur when payer editing systems do not recognize certain billing combinations. The section outlines general steps for confirming whether a denial is caused by software limitations or by payer policy.
What You Will Learn
- How payer definitions of global periods can influence claim processing
- Why claims-editing systems may affect denials involving evaluation and management services and surgery
- How to verify whether a denial is tied to payer policy or software limitations
- General approaches to reducing appeal burden and improving billing workflow efficiency
Who Should Read This
- Medical coders
- Billing specialists
- Revenue cycle staff
- Compliance auditors
- Physician practice managers
Modifiers Discussed
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