CurrentBlue Cross Blue Shield - MainePolicy G-06003

Modifiers 25 and 57: Evaluation and Management with Global Procedures

This reimbursement policy governs when separate payment is allowed for Evaluation and Management (E/M) services billed with modifier 25 or modifier 57 in conjunction with global surgical procedures for Blue Cross Blue Shield - Maine members and applicable providers.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy G-06003

Change TypeOperational change — nonreimbursable code added

Effective DateApr 1, 2026

Next Review Date

Key ActionDo not separately bill CPT 99211 with modifier 25 — such claims will be nonreimbursable.

SourceLink

POLICY UPDATE CHANGES

Added language to the Nonreimbursable section to not allow separate reimbursement when procedure 99211 is submitted with modifier 25.

100%reimbursement rate for eligible separate E/M services

99211explicitly nonreimbursable when billed with modifier 25

90-daymodifier 25 and 57 applicability includes major surgery global period

0/10-daymodifier 25 allowed for minor surgery; modifier 57 not allowed for minor surgeries

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When Separate E/M Payment Is Allowed

Coverage criteria for modifiers 25 and 57

Covered when ALL of the following criteria are met for modifier 25, and when ALL criteria for modifier 57 are met; specific nonreimbursable rules also apply.

ALL of the following

ALL of the following
- The appropriate level of E/M service is billed
  Exact level must be supported by documentation.
- Modifier 25 is appended to the E/M service and the E/M is significant and separately identifiable above and beyond the other service or procedure (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

ALL of the following

ANY of the following
- CPT code 99211 is billed with modifier 25
  Claims with CPT 99211 plus modifier 25 are nonreimbursable per policy change; such claims will not be paid.

ALL of the following

ALL of the following
- E/M visit resulted in the initial decision to perform a major surgical procedure (day prior to or day of the procedure)
- Documentation supports the decision and the E/M visit is billed with modifier 57
- Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate when allowed

ALL of the following

ANY of the following
- The decision to perform the surgery was made prior to the E/M visit (i.e., E/M visit did not result in the initial decision)
- E/M visit is for a minor surgery (0- or 10-day global period)
  Modifier 57 is not allowed for minor surgeries because the decision is typically routine preoperative care.
- A service billed with a CPT code other than an E/M code is billed with modifier 57
  Modifier 57 applies only to qualifying E/M services.

ALL of the following

Health Plan reserves the right to perform post-payment review and to request medical records to support payment
Failure to use modifier 25 or 57 correctly may result in claim denial or recoupment
Operational note: Global surgical package periods apply — modifier 25 may be allowed for E/M on same day as major (90-day) or minor (0- or 10-day) surgery when criteria are met; modifier 57 applies only to major (90-day) global procedures as described

Modifiers, Codes, and Reimbursement

Modifiers and example codesCPTNot Covered

99211

Excluded from separate reimbursement when billed with modifier 25

Modifier usage notesModifier

25	Append to E/M service when the E/M is significant and separately identifiable from the procedure; reimbursement allowed when documentation supports the separate E/M and appropriate level is billed (reimbursement 100% of applicable fee schedule or contracted/negotiated rate). Failure to use correctly may result in nonpayment; Health Plan may perform post-payment review.
57	Use to indicate an E/M visit resulted in the initial decision to perform a major surgery (90-day global); reimbursement allowed when documentation supports decision (reimbursement 100% of applicable fee schedule or contracted/negotiated rate). Not allowed for minor surgeries (0- or 10-day global) or when decision for surgery was made prior to the E/M visit; not to be used with non-E/M CPT codes.

Modifiers (informational)Modifier

25	Indicates on the day a procedure the member's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care; documentation must substantiate the E/M service. Allowed with major and minor surgery when criteria met; reimbursement 100% of applicable fee schedule or contracted/negotiated rate.
57	Indicates an E/M service that resulted in the initial decision to perform a major surgery on the day prior to or day of the procedure (90-day global). Allowed when documentation supports that the E/M resulted in the decision for surgery; not allowed for minor surgeries, when the decision was made prior to the visit, or when billed with non-E/M CPT codes.

Reimbursement rate for eligible E/M

Reimbursement rate100% of the applicable fee schedule or contracted/negotiated rate for qualifying separate E/M services

Applies whenE/M is significant and separately identifiable and billed with modifier 25 or modifier 57 (for major surgery) and documentation supports the separate service

Provider same-day requirementReimbursement applies when the significant E/M is performed by the same provider on the same day as the original service or procedure

Documentation, Review, and Billing Requirements

Documentation Required

Documentation and review — provider responsibilities

Providers must maintain and make available clinical documentation to support any E/M service billed on the same day as a procedure using modifier 25 or an E/M service that results in the initial decision to perform surgery billed with modifier 57. Documentation should clearly demonstrate that the E/M was significant and separately identifiable from the procedure or that the E/M led to the decision for surgery. Be prepared for post-payment review, medical record requests, and audits; failure to provide adequate documentation may result in claim denial, payment recovery, or adjustment.

Affected modifiers: 25, 57
Medical record must document separate history, exam, and medical decision-making (or clearly justify why elements differ)
Services must meet prior authorization and medical necessity requirements when applicable
Be responsive to post-payment medical record requests to avoid denials or recoupment

Modifier Definitions

Modifier 25

Modifier 25 - definitionIndicates 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; must be substantiated by documentation.

Modifier 57

Modifier 57 - definitionIndicates an E/M service that resulted in the initial decision to perform a major surgery on the day prior to or day of the procedure; used to support separate reimbursement for E/M associated with major (90-day) surgical global periods.