{"id":20765,"date":"2019-02-28T09:30:07","date_gmt":"2019-02-28T14:30:07","guid":{"rendered":"http:\/\/www.carecloud.com\/continuum\/?p=20765"},"modified":"2025-10-21T17:40:24","modified_gmt":"2025-10-21T17:40:24","slug":"procedure-coding-57-modifier","status":"publish","type":"post","link":"https:\/\/carecloud.com\/continuum\/procedure-coding-57-modifier\/","title":{"rendered":"Procedure Coding: When to Use The 57 Modifier"},"content":{"rendered":"<h3>This is part of the Modifier Series, the articles include:<\/h3>\n<ul>\n<li>Modifers<a href=\"https:\/\/www.carecloud.com\/continuum\/modifier-59-25-91-guide-coders\/\"> 59, 25, and 91<\/a><\/li>\n<li>Modifier <a href=\"https:\/\/www.carecloud.com\/continuum\/procedure-coding-when-to-use-the-59-modifier\/\">59<\/a><\/li>\n<li>Modifier <a href=\"https:\/\/www.carecloud.com\/continuum\/procedure-coding-25-modifier\/\">25<\/a><\/li>\n<li>Modifier <a href=\"https:\/\/www.carecloud.com\/continuum\/modifier-26\/\">26<\/a><\/li>\n<li>Modifier <a href=\"https:\/\/www.carecloud.com\/continuum\/procedure-coding-modifier-22\/\">22<\/a><\/li>\n<li>Modifier <a href=\"https:\/\/www.carecloud.com\/continuum\/modifier-51\/\">51<\/a><\/li>\n<li>Modifier <a href=\"https:\/\/www.carecloud.com\/continuum\/procedure-coding-modifier-53\/\">53<\/a><\/li>\n<li>Modifier <a href=\"https:\/\/www.carecloud.com\/continuum\/procedure-coding-58-modifier\/\">58<\/a><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">The 57 modifier is an ongoing source of confusion for physicians and medical staff alike. But it\u2019s not so difficult once you really understand how it should be used. It is more than just another informational modifier &#8211; it actually affects reimbursement. <\/span><span style=\"font-weight: 400;\"><br \/>\n<\/span><span style=\"font-weight: 400;\"><br \/>\n<\/span><span style=\"font-weight: 400;\">Correct use of modifier 57 is similar to how modifier 25 is used, a modifier which you may be more familiar with and was examined in another article in this series. Whereas modifier 25 is more appropriate for E\/Ms performed in addition to minor procedures, modifier 57 is reserved for E\/Ms that result in major procedures. Let\u2019s take a moment and review when to correctly use the modifier 57 to ensure your practice is getting paid for all the services they render.<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Defining Modifier 57<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">It\u2019s generally understood that modifier 57 applies to an E\/M from which a \u201cdecision for surgery\u201d has been made by the physician. But there\u2019s something more you should know. Surgical procedures aren\u2019t the only procedures where modifier 57 can and should apply. In fact, the CPT manual states modifier 57 can be used on any E\/M during which the physician decides a \u201cmajor\u201d procedure is necessary. <\/span><span style=\"font-weight: 400;\"><br \/>\n<\/span><span style=\"font-weight: 400;\"><br \/>\n<\/span><span style=\"font-weight: 400;\">While the CPT manual does not specify \u201cmajor\u201d in these instances, CMS (Centers for Medicare and Medicaid Services) does, and CMS sets the standard for most payers\u2019 guidelines. Per CMS, a major procedure is a procedure with 90 global days. And as we know, that procedure may or may not necessarily be surgical in nature. <\/span><\/p>\n<p><span style=\"font-weight: 400;\">As mentioned before, it may help to think of 57 as the 25 equivalent when it comes to getting the pre-surgery E\/M paid. This is because if a major procedure is done and the preceding E\/M was lacking the 57 modifier, the payer will assume the E\/M was inclusive to the other services billed, and will not pay separately for it.<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Important Points<\/span><\/h2>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Initial evaluation prior to major surgery and\/or procedure is always payable.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Modifier 57 should be appended to any E\/M service <\/span><i><span style=\"font-weight: 400;\">on the day of or the day before<\/span><\/i><span style=\"font-weight: 400;\"> said procedure when the E\/M service results in the decision to go to surgery. This informs the payer that the physician determined the surgery was medically necessary.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Modifier 57 should only be appended to E\/M codes.<\/span><span style=\"font-weight: 400;\"><br \/>\n<\/span><\/li>\n<\/ul>\n<h2><span style=\"font-weight: 400;\">Clinical Scenarios<\/span><\/h2>\n<h3><b>Example 1<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">A surgeon sees a patient in the emergency department, then performs CPT code 65285 <\/span><i><span style=\"font-weight: 400;\">repair of laceration; cornea and\/or sclera, perforating, with reposition or resection of uveal tissue<\/span><\/i><span style=\"font-weight: 400;\"> on the same day. Since this surgical code has a 90 day global period, the correct way to bill the E\/M for separate, appropriate payment is 99284-57 <\/span><i><span style=\"font-weight: 400;\">emergency department visit for the evaluation and management of a patient<\/span><\/i><span style=\"font-weight: 400;\">; 65285.<\/span><\/p>\n<h3><b>Example 2<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">An orthopedist examines their patient and discerns the need to perform non-surgical fracture care.<\/span> <span style=\"font-weight: 400;\">Closed treatment of a clavicle fracture, whether CPT 23505-with manipulation, or CPT 23500-without manipulation, is not technically surgical in nature, but is a major procedure that has a 90-day global period. In this case, separate payment of an E\/M service with modifier 57 is appropriate. <\/span><\/p>\n<h3><b>Example 3<\/b><\/h3>\n<p><span style=\"font-weight: 400;\">A patient presents to the emergency department (ED) with abdominal pain and fever. The consulting surgeon documents a level 3 outpatient consult and decides at that visit to perform an emergency appendectomy. The appropriate coding for payment of the preceding E\/M is 99243-57; 44950.<\/span><\/p>\n<h2><span style=\"font-weight: 400;\">Incorrect Use of Modifier 57<\/span><\/h2>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Appending to a surgical procedure code.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Appending to an E\/M procedure code performed the same day as a <\/span><i><span style=\"font-weight: 400;\">minor<\/span><\/i><span style=\"font-weight: 400;\"> surgery\/procedure.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Reporting on the day of surgery for a pre-planned surgery.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Reporting on the day of surgery that will be performed in stages or multiple sessions.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Reporting on the E\/M for the decision for surgery, but the surgery is scheduled in 2 or more days.<\/span><span style=\"font-weight: 400;\"><br \/>\n<\/span><\/li>\n<\/ul>\n<h2><span style=\"font-weight: 400;\">Final thoughts<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Separate payment of an E\/M service prior to surgery by using modifier 57 is appropriate &#8211; when properly documented. Remember to use 57 when the decision was made to move forward with a major procedure in order to be compensated accordingly. Familiarizing yourself with modifiers, like 57, that are applicable for your provider and\/or practice will ensure not only that the modifier is used appropriately, but that you secure the reimbursement you\u2019re owed.<\/span><span style=\"font-weight: 400;\"><br \/>\n<\/span><\/p>\n<p><span style=\"display: none;\" data-sumome-listbuilder-embed-id=\"63167955acecc7c017d1349e21976b34c69d1681cdcbe88c9a25211c5006fd11\">DUMMYTEXT<\/span><\/p>\n<h4><strong>Sources:<\/strong><\/h4>\n<ul>\n<li><a href=\"https:\/\/www.aapc.com\/blog\/36675-modifier-57-is-for-more-than-surgery\/\"><span style=\"font-weight: 400;\">https:\/\/www.aapc.com\/blog\/36675-modifier-57-is-for-more-than-surgery\/<\/span><\/a><\/li>\n<li><a href=\"https:\/\/www.codingintel.com\/confusion-modifier-57\/\"><span style=\"font-weight: 400;\">https:\/\/www.codingintel.com\/confusion-modifier-57\/<\/span><\/a><\/li>\n<li><a href=\"https:\/\/www.outsourcestrategies.com\/blog\/learn-the-facts-about-modifier-57.html\"><span style=\"font-weight: 400;\">https:\/\/www.outsourcestrategies.com\/blog\/learn-the-facts-about-modifier-57.html<\/span><\/a><\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>This is part of the Modifier Series, the articles include: Modifers 59, 25, and 91 Modifier 59 Modifier 25 Modifier 26 Modifier 22 Modifier 51 Modifier 53 Modifier 58 The 57 modifier is an ongoing source of confusion for physicians and medical staff alike. But it\u2019s not so difficult once you really understand how it [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":43373,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[389],"tags":[],"class_list":["post-20765","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-resources"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Procedure Coding: When to Use The 57 Modifier - Continuum<\/title>\n<meta name=\"description\" content=\"It\u2019s generally understood that modifier 57 applies to an E\/M from which a \u201cdecision for surgery\u201d has been made by the physician.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/carecloud.com\/continuum\/procedure-coding-57-modifier\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Procedure Coding: When to Use The 57 Modifier - Continuum | CareCloud\" \/>\n<meta property=\"og:description\" content=\"It\u2019s generally understood that modifier 57 applies to an E\/M from which a \u201cdecision for surgery\u201d has been made by the physician. In fact, the CPT manual states modifier 57 can be used on any E\/M during which the physician decides a \u201cmajor\u201d procedure is necessary.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/carecloud.com\/continuum\/procedure-coding-57-modifier\/\" \/>\n<meta property=\"og:site_name\" content=\"Continuum\" \/>\n<meta property=\"article:published_time\" content=\"2019-02-28T14:30:07+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-21T17:40:24+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/carecloud.com\/continuum\/wp-content\/uploads\/2019\/01\/Procedure-Coding-When.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1440\" \/>\n\t<meta property=\"og:image:height\" content=\"576\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"cc_continuum\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"cc_continuum\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/procedure-coding-57-modifier\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/procedure-coding-57-modifier\\\/\"},\"author\":{\"name\":\"cc_continuum\",\"@id\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/#\\\/schema\\\/person\\\/6af17e75a684cc5cd23741e014351348\"},\"headline\":\"Procedure Coding: When to Use The 57 Modifier\",\"datePublished\":\"2019-02-28T14:30:07+00:00\",\"dateModified\":\"2025-10-21T17:40:24+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/procedure-coding-57-modifier\\\/\"},\"wordCount\":740,\"publisher\":{\"@id\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/procedure-coding-57-modifier\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/wp-content\\\/uploads\\\/2019\\\/01\\\/Procedure-Coding-When.webp\",\"articleSection\":[\"Resources\"],\"inLanguage\":\"en-US\"},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/procedure-coding-57-modifier\\\/\",\"url\":\"https:\\\/\\\/carecloud.com\\\/continuum\\\/procedure-coding-57-modifier\\\/\",\"name\":\"Procedure Coding: When to Use The 57 Modifier - 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