Modifier 57
Decision for surgery
Use it when
- An E/M on the day of or day before a major procedure at which the decision to operate was made
- Where the surgery carries a 90-day global period
Do not use it when
- Minor procedures with a 10-day or zero-day global period — modifier 25 applies there
- A visit confirming a decision made at an earlier encounter
- Routine preoperative clearance or history taking after the decision was already made
A worked example
A patient presents with acute symptoms. The surgeon evaluates them, reaches a diagnosis, and decides that surgery is required. The operation is performed the following morning.
That evaluation is what produced the decision to operate. Without modifier 57 it falls inside the surgical package and is not separately paid, because E/M services on the day of or before a major procedure are otherwise bundled.
Reported with modifier 57, it is separately payable. The note has to show that the decision was reached at that encounter, not confirmed at it.
What decides it
The choice between modifiers 57 and 25 is determined by the global period of the procedure, not by the complexity of the evaluation. Major procedures carrying a 90-day global take 57; minor procedures take 25.
The word 'initial' is doing real work. A visit at which an already-made decision is confirmed, consent obtained and preoperative instructions given is part of the surgical package. The visit where the decision was actually reached is not.
This is a modifier practices under-use rather than over-use. Surgeons frequently perform a substantial evaluation that leads directly to an operation and never bill it, because the visit and the surgery feel like one episode of care.
Denial codes this affects
Modifiers often confused with this one
Terms used here — E/M Coding · Modifier · Denial
How we handle it — Medical Coding · Claims Management · Denial Management
Every CPT and HCPCS modifier with a guide
Coverage attestation
Evaluation and management
Global period
Multiple and bilateral
Primary sources
What the payers and code-set maintainers actually publish about modifier 57.
- Global Surgery booklet (opens in a new tab)
Centers for Medicare & Medicaid Services — What the 10 and 90-day global periods include, and which modifiers break out of them. The authority behind most postoperative bundling disputes.
- Medicare Claims Processing Manual (opens in a new tab)
Centers for Medicare & Medicaid Services — The operative manual for how Medicare claims must be coded, submitted, adjusted and appealed. When a payer policy and a vendor's advice disagree, this settles it.
- CPT code set (opens in a new tab)
American Medical Association — Maintainer of CPT. Annual changes to CPT are the most common cause of a sudden, unexplained rise in denials each January.
Questions about modifier 57
For an evaluation and management service on the day of or the day before a major procedure, at which the initial decision to operate was made. Without it, that E/M falls inside the surgical package and is not separately paid.
The global period of the procedure decides it, not the complexity of the evaluation. Major procedures with a 90-day global take modifier 57; minor procedures with a 10-day or zero-day global take modifier 25.
Only if the decision to operate was reached at that visit. A visit confirming an earlier decision, obtaining consent and giving preoperative instructions is part of the surgical package.
Under-used. Surgeons frequently perform a substantial evaluation leading directly to an operation and never bill it, because the visit and the surgery feel like a single episode of care.
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