CurrentAnthemPolicy G-06003

Modifiers 25 and 57: Evaluation and Management with Global Procedures

Defines Anthem HealthKeepers Inc. reimbursement rules for separate payment of Evaluation and Management (E/M) services billed with modifier 25 or modifier 57 in relation to procedures with global periods; applies to Anthem HealthKeepers Plus Medicaid providers.

Policy Summary

PayerAnthem

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy G-06003

Change TypeNo material changes

Effective DateMay 22, 2024

Next Review Date

Key ActionAppend Modifier 25 or 57 and document that the E/M was significant and separately identifiable (or resulted in the initial decision for surgery) to qualify for separate reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%reimbursement rate for eligible E/M with Mod 25 or Mod 57

CPT 99211specifically nonreimbursable with Modifier 25

90dmajor surgery global period

0/10dminor surgery global period

Coverage Criteria for E/M with Global Procedures

Coverage Criteria for Modifiers 25 and 57

Anthem allows separate reimbursement for qualifying E/M services when modifier criteria and documentation requirements are met.

ALL of the following

Required: Appropriate level of E/M service is billed
Required: Modifier 25 is appended to the E/M service
Required: Documentation clearly states the reason for the E/M service
Required: Documentation supports that the member's condition required a significant, separately identifiable E/M above and beyond the usual preoperative and postoperative care associated with the procedure

Policy Summary

PayerAnthem

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy G-06003

Change TypeNo material changes

Effective DateMay 22, 2024

Next Review Date

Key ActionAppend Modifier 25 or 57 and document that the E/M was significant and separately identifiable (or resulted in the initial decision for surgery) to qualify for separate reimbursement.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Relevant Codes and Coding Rules

ModifiersModifier

Modifier 25	Indicates significant, separately identifiable E/M on same day as procedure
Modifier 57	Indicates E/M that resulted in the initial decision to perform major surgery

CPT exclusionsCPTNot Covered

CPT 99211

Not eligible for separate reimbursement with Modifier 25

E/M level requirement — appropriate level must be billed and documented as significant and separately identifiable

RequirementThe appropriate level of E/M service must be billed.

Documentation standardDocumentation must show the E/M was significant and separately identifiable above and beyond the usual preoperative and postoperative care.

Modifier useModifier 25 must be appended to the E/M service to indicate it is above and beyond the other service or procedure.

Denial riskFailure to use Modifier 25 correctly may result in denial of the E/M service.

Payment basisReimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate when criteria are met.

Authorization, Documentation, and Record Review

Prior Authorization

Authorization & Documentation: medical necessity and records must support billed services

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; Anthem may request medical records to support payment. Follow proper billing and submission guidelines and ensure services billed with CPT/HCPCS/revenue codes are fully supported in the medical record and/or office notes.

Use industry-standard, compliant CPT, HCPCS, and/or revenue codes on all claim submissions.
Ensure medical records/office notes fully support billed services.
Noncompliance may lead to claim rejection, denial, or recovery/recoupment of payment.

Documentation Required

Record Review & Verification: Anthem may request records and perform post-payment review for Modifier 57

Anthem reserves the right to request medical records to support payment for E/M visits billed with Modifier 57 and may perform post-payment review for related claims; failure to use Modifier 57 when appropriate may result in denial.

Anthem may request medical records for review to support payment for the E/M visit billed with Modifier 57.
Failure to append Modifier 57 when appropriate may result in claim denial.
Post-payment review and recoupment actions are possible if documentation/billing guidelines are not followed.

Modifier Definitions

Modifier 25 — indicates a significant, separately identifiable E/M on the same day as a procedure or service

DefinitionUsed to indicate that on the day a procedure or service was performed, the member's condition required a significant, separately identifiable E/M service above and beyond the original service or usual preoperative and postoperative care.

PurposeIndicates a significant, separately identifiable E/M performed on the same day as a procedure or service.

Documentation requirementDocumentation must substantiate the E/M level reported and show the member's condition required the separate E/M.

Reimbursement noteWhen criteria are met, separate reimbursement is allowed (see policy for applicable global periods and payment rate).

Modifier 57 — indicates an E/M that resulted in the initial decision to perform surgery on the day of a major procedure

DefinitionUsed to indicate an E/M service that resulted in the initial decision to perform a surgery on the day of a major procedure or service.

TimingApplies to E/M visits provided on the day prior to or the day of a major surgery (90-day global period).

Documentation and reviewAnthem may request medical records to support payment for E/M visits billed with Modifier 57.

ExclusionsNot allowed if the decision for surgery was made prior to the E/M visit or for minor surgeries (0- or 10-day globals).

Policy Revision History

2024-05-22Review & effectiveLatest

Review approved and policy effective; updated policy title to 'Modifiers 25 and 57'.

2023-04-01Update - nonreimbursable code

Policy language updated to indicate CPT code 99211 is not eligible for reimbursement with Modifier 25 (review approved 08/10/2022, effective 04/01/2023).

2022-04-27Consolidation

Combined separate policies for Modifier 57 and Modifier 25 into a single policy (G-06003) and added major surgery language for Modifier 25; review approved and effective 04/27/2022.

2019-04-01Content update

Modifier 25 description language updated and major surgery policy language added (review approved 09/28/2017, effective 04/01/2019).

2016-06-06Template update

Policy template updated (review approved 06/06/2016).

2014-06-09Template update

Policy template updated (review approved 06/09/2014).

2013-11-01Initial approval & effective

Initial approval and effective date for the original policy (11/01/2013).