Quick Facts

Status

57

Modifier 57

Decision for Surgery

Active

Global Period

90-day Global Period

Modifier

57

Applies To

Major Surgical Procedures

Category

Use With

Evaluation & Management

E/M CPT Codes

What is Modifier 57?

Modifier 57 is appended to an evaluation and management (E/M) service when the visit results in the initial decision to perform a major surgical procedure. It tells the payer that the E/M service was significant because it led directly to the decision for surgery and should be reimbursed separately from the operation.

Modifier 57 is only appropriate for major surgeries with a 90-day global period and should not be reported for minor procedures.

When to Use

  • An office visit results in the decision to perform major surgery.

  • The physician evaluates a new condition requiring surgery.

  • The E/M service occurs the day before or the same day as surgery.

  • The surgery has a 90-day global period.

Documentation Requirements

  • Clearly document the patient's condition.

  • Support medical necessity for the evaluation.

  • Document the physician's decision to proceed with surgery.

  • Include the assessment, treatment plan, and surgical recommendation.

  • Maintain complete E/M documentation.

Examples
Example 1

A patient presents with severe gallbladder pain. After a complete evaluation, the surgeon diagnoses acute cholecystitis and schedules a laparoscopic cholecystectomy the same day. Modifier 57 is appended to the E/M service because the visit resulted in the decision for surgery.

Example 2

A patient is evaluated for severe carotid artery disease. Following the examination and review of diagnostic imaging, the vascular surgeon recommends carotid endarterectomy. The office visit qualifies for Modifier 57 because it led to the decision to perform major surgery.

Billing Tips

  • Use Modifier 57 only with E/M services.

  • Report Modifier 57 only for surgeries with a 90-day global period.

  • Do not use Modifier 57 for minor surgical procedures.

  • Ensure documentation clearly supports the decision for surgery.

  • Review payer-specific billing guidelines.

Common Denial Reasons

  • Surgery does not have a 90-day global period.

  • Documentation does not support the decision for surgery.

  • Modifier appended to a procedure code instead of an E/M code.

  • Medical necessity is not clearly documented.

  • Insufficient E/M documentation.

Related Modifiers
Modifier 24

Unrelated E/M Service During the Postoperative Period

Modifier 25

Significant, Separately Identifiable E/M Service

Modifier 26

Professional Component

Modifier 50

Bilateral Procedure

Additional Resources

Modifier 57 is commonly used by surgeons and specialists when an evaluation directly leads to a major surgical procedure. Proper documentation of the decision-making process is essential for accurate reimbursement.

For comprehensive billing guidance, coding scenarios, documentation requirements, payer policies, modifier comparisons, and real-world examples, visit ModifierLookup.com for the complete Modifier 57 reference guide.