CurrentAnthemPolicy G-06003

Modifiers 25 and 57: Evaluation and Management with Global Procedures

Defines Anthem New York Medicaid reimbursement rules for billing Evaluation and Management (E/M) services with Modifiers 25 and 57 when performed the day of or day prior to procedures, and specifies when separate reimbursement is allowed or disallowed.

Policy Summary

PayerAnthem

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy G-06003

Change TypeNo material change

Effective DateMay 22, 2024

Next Review Date

Key ActionAnthem may request medical records for post-payment review to support payment for E/M visits billed with Modifiers 25 or 57; ensure documentation justifies the separate E/M.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%reimbursement rate for qualifying E/M services when allowed

99211 excluded99211 not reimbursable with Modifier 25 except vaccine administration

90dglobal period for major surgery

0/10dglobal period for minor surgery

When E/M Is Separately Reimbursable

Policy Summary

PayerAnthem

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy G-06003

Change TypeNo material change

Effective DateMay 22, 2024

Next Review Date

Key ActionAnthem may request medical records for post-payment review to support payment for E/M visits billed with Modifiers 25 or 57; ensure documentation justifies the separate E/M.

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.

ALL of the following

Anthem allows separate reimbursement for E/M performed on the same day as major (90-day global) or minor (0- or 10-day global) surgery when billed with Modifier 25.
Reimbursement is 100% of the applicable fee schedule or contracted/negotiated rate for the qualifying E/M service.
ALL of the following
- The appropriate level of E/M service is billed.
- Modifier 25 is appended to the E/M service and the E/M is above and beyond the other service or procedure provided (including usual preoperative and postoperative care).
- The reason for the E/M service is clearly documented in the member's medical record.
- Documentation supports that the member's condition required the significantly separate E/M service.

Modifier 25 — exclusions (do not reimburse)

CPT code 99211 billed with Modifier 25 is not reimbursable except when billed for vaccine administration.

ALL of the following

Anthem allows separate reimbursement for an E/M visit provided on the day prior to or the day of a major surgery (90-day global) when billed with Modifier 57 to indicate the E/M resulted in the initial decision to perform the major surgical procedure.
Reimbursement is 100% of the applicable fee schedule or contracted/negotiated rate for the qualifying E/M visit.
Anthem may request medical records for review to support payment for E/M visits billed with Modifier 57; failure to use the modifier when appropriate may result in denial.

Modifier 57 — exclusions (do not reimburse)

An E/M visit the day before or day of surgery when the decision to perform the surgery was made prior to the E/M visit.
An E/M visit for minor surgeries (0-day or 10-day global period), since decision for minor surgery is usually routine preoperative care.
A service billed with a CPT code other than an E/M code when billed with Modifier 57.

ALL of the following

Failure to use Modifiers 25 or 57 correctly may result in denial or recoupment; services must meet authorization and medical necessity requirements and follow state, provider, and CMS contracts/requirements.
Anthem reserves the right to perform post-payment review and request medical records to support payment for E/M visits billed with Modifiers 25 or 57.

ALL of the following

When allowed, payment for qualifying E/M services is 100% of the applicable fee schedule or contracted/negotiated rate.

ALL of the following

Allowances apply unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

CPT Code Exceptions and Reimbursement

CPT code exceptionsCPTNot Covered

99211

Office or other outpatient visit for the evaluation and management of an established patient; lowest-level E/M (not reimbursable with Modifier 25 except when billed for vaccine administration)

Reimbursement percentage — qualifying E/M

Reimbursement percentage100% of the applicable fee schedule or contracted/negotiated rate for qualifying E/M services

Applies when Modifier 25 or 57 is properly appendedPayment at 100% applies when the E/M meets the policy criteria and the correct modifier is used

Same-provider, same-day provisionReimbursement covers E/M performed by the same provider on the same day as the original service or procedure when criteria are met

Documentation and Review Requirements

Documentation Required

Record review and documentation when billing Modifiers 25 or 57

Anthem may request medical records for post-payment review to support payment for E/M visits billed with Modifiers 25 or 57. When billing Modifier 25, append the modifier, bill the appropriate E/M level, and ensure the reason for and documentation of the separate E/M clearly demonstrate the member's condition required a significantly separate service; failure to use Modifier 25 correctly may result in denial. For Modifier 57, ensure the E/M visit documentation supports that the visit resulted in the initial decision to perform a major surgical procedure; Anthem may request medical records and failure to use Modifier 57 appropriately may result in claim denial.

Append Modifier 25 to the qualifying E/M and bill the appropriate E/M level; documentation must show the E/M was significant and separate from usual pre/post‑operative care. (Chunk 3)
Anthem reserves the right to perform post‑payment review of claims with Modifier 25 and may request medical records. (Chunk 3)
For Modifier 57, document that the E/M resulted in the initial decision to perform a major surgery; Anthem may request medical records to support payment. (Chunk 5)
Failure to use Modifiers 25 or 57 correctly may result in denial of the E/M service or claim. (Chunks 3, 5)

Modifier Definitions

Modifier 25 — definition and usage

DefinitionModifier 25 indicates that on the day a procedure or service was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the original service or the usual preoperative and postoperative care.

Usage noteAppend Modifier 25 to the E/M service when the E/M level billed is appropriate, clearly documented, and substantiates a separate E/M beyond routine care; failure to use correctly may result in denial.

DocumentationMedical record must clearly document the reason for and that the condition required the separate, significant E/M service; Anthem may perform post-payment review.

Modifier 57 — definition and usage

DefinitionModifier 57 indicates an E/M service that resulted in the initial decision to perform a major surgery on the day prior to or the day of the procedure.

Usage noteUse Modifier 57 when the E/M visit led to the initial decision to perform the major surgical procedure; failure to use when appropriate may result in denial.

LimitationsModifier 57 applies to major surgery (90-day global); it is not reimbursed when the decision for surgery was made prior to the E/M visit or for minor surgeries per policy.