CurrentBlue Cross Blue Shield - MainePolicy C-09011

Modifiers 25 and 57: Evaluation and Management with Global Procedures

Defines Anthem Blue Cross and Blue Shield - Maine reimbursement rules for separate payment of Evaluation and Management (E/M) services when billed with modifiers 25 or 57, and outlines circumstances when those modifiers are reimbursable or not; applies to providers submitting commercial claims to the payer.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy C-09011

Change TypeNo material change

Effective DateNov 23, 2022

Next Review Date

Key ActionBe prepared to provide medical records if billing an E/M visit with modifier 57 to support payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%reimbursement of eligible separate E/M when criteria met

50%same-day preventive + problem-oriented E/M reduction

CPT 99211explicitly nonreimbursable example

90-daymajor surgery global period

1policy usage statement

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Coverage Criteria for Modifiers 25 and 57

Modifier-specific coverage rules

Conditions under which separate reimbursement for E/M services with modifiers 25 or 57 is allowed or disallowed.

Modifier 25 - same day as global procedures: Allow separate reimbursement at 100% when modifier 25 is appended and documentation supports a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care; the appropriate level of E/M is billed; the reason for the E/M is clearly documented; and the documentation supports that the member's condition required the separate E/M service.

Modifier 25 - preventive + problem-oriented E/M: When a preventive medicine exam and a problem-oriented E/M are performed on the same day by the same provider, modifier 25 must be appended to either the problem-oriented or the preventive E/M code; the problem-oriented E/M code will be reduced by 50%; and appropriate diagnosis codes must be billed for the respective visits.

Modifier 25 - nonreimbursable situations: The Health Plan will not allow reimbursement when CPT code 99211 is billed with modifier 25, or when two separate E/M services are reported on the same day by the same provider or group.

Modifier 57 - major surgery decision: Allow separate reimbursement at 100% for an E/M visit provided on the day of or the day before a major surgery (90-day global period) when billed with modifier 57 to indicate the visit resulted in the initial decision to perform the major surgical procedure; the payer may request medical records to support payment; failure to use modifier 57 when appropriate may result in claim denial.

Modifier 57 - nonreimbursable situations: The Health Plan will not allow reimbursement for modifier 57 for E/M visits associated with minor surgeries (0- or 10-day global period) or when the service billed is a CPT code other than an E/M code.

Coding and Procedure References

Modifiers and referenced CPTModifier | CPT

Modifier 25	Significant, separately identifiable E/M service by the same provider on the same day as another service or procedure.
Modifier 57	Decision for surgery; E/M visit that results in the initial decision to perform a major surgery.
CPT 99211	Referenced as not eligible for reimbursement with modifier 25 (except Maine allows modifier 25 to be appended).

Anthem/BCBS trade names and affiliatesmixed

No codes listed

Same-day preventive + problem-oriented E/M reduction

Reduction appliedProblem-oriented E/M code will be reduced by 50% when performed the same day as a preventive (wellness) exam; appropriate diagnosis codes must be billed.

Modifier requirementModifier 25 must be appended to either the problem-oriented or preventive E/M code when both are performed same day.

Documentation requirementThe reason for the E/M service must be clearly documented in the member's medical record.

Appropriate level billedThe appropriate level of E/M service must be billed for the problem-oriented visit.

Provider Actions, Documentation, and Policy Applicability

Documentation Required

Medical record request for Modifier 57

The payer reserves the right to request medical records to support payment for an E/M visit billed with modifier 57; reimbursement is based on 100% of the applicable fee schedule or contracted rate when criteria are met.

Records may be requested to verify that the E/M visit resulted in the initial decision to perform a major surgical procedure.
Failure to use modifier 57 when appropriate may result in claim denial.

Prior Authorization

Authorization and medical necessity

Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and the member's state of residence; providers must follow proper billing and submission guidelines and use industry‑standard codes supported by the medical record.

Use CPT, HCPCS, and/or revenue codes that are fully supported in the medical record or office notes.

Definitions and Policy Usage

Modifier 25

DefinitionSignificant, separately identifiable Evaluation and Management (E/M) service provided by the same physician or other qualified health care professional on the same day as another procedure or service.

Reimbursement conditionSeparate reimbursement allowed at 100% when modifier 25 is appended and documentation supports an E/M above and beyond usual pre/post‑operative care.

Documentation requiredDocumentation must show the E/M is above and beyond the other service, the appropriate level is billed, and the reason is clearly documented.

Modifier 57

DefinitionIndicates the E/M visit resulted in the initial decision to perform surgery (Decision for Surgery).

Reimbursement conditionAllow separate reimbursement at 100% for an E/M visit on the day of or day before a major surgery (90‑day global) when billed with modifier 57 and documentation supports the decision for surgery.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy C-09011

Change TypeNo material change

Effective DateNov 23, 2022

Next Review Date

Key ActionBe prepared to provide medical records if billing an E/M visit with modifier 57 to support payment.

SourceLink

On This Page

Failure to follow coding/billing guidelines may result in recoupment, rejection, or denial of the claim.

Documentation Required

Policy applicability and update

This reimbursement policy is subject to applicable federal and state laws and the terms, conditions, and limitations of a member's benefit plan; the payer may review and update policies periodically.

Policy updates will be published to the website; the payer reserves the right to recoup payments to the effective date if implementation is delayed.
Reproduction of the policy is prohibited without permission.

Medical record requestThe payer may request medical records to support payment for an E/M visit billed with modifier 57.

Anthem/Blue Cross and Blue Shield trade names and affiliates

Primary trade nameAnthem Blue Cross and Blue Shield is the trade name used by various affiliated entities (examples listed by state, including Anthem Health Plans of Maine, Inc. for Maine).

State-specific entitiesLists state entities such as Rocky Mountain Hospital and Medical Service, Inc. (Colorado/Nevada), Anthem Health Plans of New Hampshire, Inc., Blue Cross Blue Shield of Wisconsin, and others as applicable by state.

Underwriting vs administrationSome named entities underwrite products; others administer benefits or provide administrative services for self‑funded plans—roles vary by entity and state.

Use of Reimbursement Policy

ApplicabilityPolicy is subject to federal and state laws and the terms, conditions, and limitations of a member's benefits on the date of service.

Policy updatesReimbursement policies may be reviewed and updated periodically; the payer reserves the right to revise policies.

Reproduction restrictionNo part of the publication may be reproduced, stored, or transmitted in any form without permission from Anthem Blue Cross and Blue Shield.