If you think of modifier 57 as the “decision for surgery” modifier, it’s time to change your mind. Modifier 57 applies when the physician determines the need for any major procedure—whether surgical or non-surgical.
“Major” Means 90-Day Global Period
The CPT® manual doesn’t define “major” or “minor” procedures, but the Centers for Medicare & Medicaid Services (CMS) does, and many payers follow CMS’s lead. Specifically, CMS defines a major procedure as any procedure with a 90-day global period, as determined by the Medicare Physician Fee Relative Value File. CMS rules further require that Medicare contractors, “pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT® modifier ‘-57’ to indicate that the service resulted in the decision to perform the procedure” (Medicare Claims Processing Manual, Chapter 12, Section 30.6.6.c).
By appending modifier 57 to an E/M code, you are alerting the payer that the E/M service—on either the day of, or the day before, a major surgical procedure—was the service at which the physician determined the surgery was appropriate and medically necessary, and is therefore not bundled to the surgery payment. For example, a surgeon sees a patient and determines (and appropriately documents) that patient needs an emergency appendectomy. Because the E/M led to the decision for surgery, both the E/M (with modifier 57 appended) and the surgery may be reported, with separate payment for each.
In a second example, an orthopedist sees a patient and determines (and documents) the need to provide non-surgical fracture care. Although closed treatment of a clavicle fracture, either with (23505) or without (23500) manipulation, is not a “surgical” service, it does have a 90-day global period, and is therefore a major procedure for which separate payment of an E/M service with modifier 57 is appropriate, when properly documented.