CurrentBlue Cross Blue Shield - MainePolicy G-06003

Modifiers 25 and 57: Evaluation and Management with Global Procedures

This policy governs when separate reimbursement is allowed for Evaluation and Management (E/M) services billed with modifier 25 or modifier 57 in association with global surgical procedures for Anthem Blue Cross and Blue Shield members; it affects providers submitting claims to the health plan.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy G-06003

Change TypeAdded nonreimbursable rule

Effective DateApr 1, 2026

Next Review Date

Key ActionAppend modifier 25 or 57 when appropriate and document the reason in the medical record; the Health Plan may request records for post-payment review.

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 for qualifying E/M

99211nonreimbursable example

90-daymajor surgery global period

0/10-dayminor surgery globals

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Coverage criteria for modifiers 25 and 57

Separate reimbursement is allowed when documentation and coding criteria are met; specific nonreimbursable situations are listed below.

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 (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
Reimbursement is 100% of the applicable fee schedule or contracted/negotiated rate when the above criteria are met
Failure to use modifier 25 correctly may result in the E/M service not being accepted; Health Plan may perform post-payment review

ALL of the following

CPT code 99211 billed with modifier 25 is not reimbursable

ALL of the following

E/M visit resulted in the initial decision to perform a major surgery (90-day global period)
Modifier 57 is appended to the E/M service
Reimbursement is 100% of the applicable fee schedule or contracted/negotiated rate when criteria are met
Health Plan may request medical records to support payment; failure to use modifier 57 when appropriate may result in claim not being accepted

Do not reimburse modifier 57 when any of the following apply

Decision to perform the surgery was made prior to the E/M visit
E/M visit is for a minor surgery with a 0- or 10-day global period (considered routine preoperative service)
The service billed is not an E/M code

ALL of the following

Health Plan may request medical records for review to support payment for E/M visits billed with modifier 25 or 57
Failure to append the correct modifier or to document appropriately may result in the claim or E/M service not being accepted

Relevant Modifiers and CPT Codes

Modifiers and relevant CPTModifierCovered

25	Modifier 25 — Significant, separately identifiable E/M on same day as procedure
57	Modifier 57 — E/M resulting in initial decision to perform major surgery
99211	CPT 99211 — nonreimbursable when billed with modifier 25

Reimbursement level (inv-03) - Coding

Reimbursement level100% of the applicable fee schedule or contracted/negotiated rate when documentation and coding criteria are met

Conditions requiredAppropriate level of E/M billed; modifier 25 or 57 appended as applicable; reason clearly documented in the member's medical record; documentation supports that E/M was significantly separate from usual pre/postoperative care

Applies whenE/M performed by same provider on same day of the original service or procedure (modifier 25) or on the day prior to or day of a major surgery when billed with modifier 57

Review rightsHealth Plan reserves the right to request medical records for review and to perform post-payment review of claims submitted with modifier 25 or 57

Failure to use modifier correctlyFailure to use modifier 25 or 57 when appropriate may result in the E/M service or claim not being accepted

Provider Documentation and Post-Payment Review

Documentation Required

Provide medical records and append modifier 25 or 57 with clear documentation

Health Plan may request medical records to support payment for E/M services billed with modifier 25 or 57; providers must append the appropriate modifier and clearly document the reason and that the E/M was significantly separate from the procedure in the member's medical record. Failure to use the modifier correctly or to document the separate E/M may result in the service not being accepted.

Append modifier 25 when the E/M is above and beyond the usual pre/postoperative care and bill the appropriate level of E/M.
Append modifier 57 when the E/M visit resulted in the initial decision to perform a major surgery (90-day global period).
Clearly document the reason for the E/M and evidence that the condition required a significantly separate E/M service.

Denial Risk

Post-payment review of claims with modifier 25

The Health Plan reserves the right to perform post-payment review of claims submitted with modifier 25; claims may be reviewed and payment subject to validation of the documentation supporting the separate E/M.

Maintain and produce medical records upon request to substantiate the use of modifier 25.
Be aware that improper use of modifier 25 may result in the E/M service not being accepted after review.

Modifier Definitions

Modifier 25 (inv-06)

Modifier 25 - 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 pre/postoperative care

Documentation requirementA significant, separately identifiable E/M service must be substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported

Usage noteAppend modifier 25 when the E/M is above and beyond the other service or procedure provided; failure to use correctly may result in claim not accepted

Plan actionsHealth Plan may perform post-payment review of claims submitted with modifier 25 and may request medical records for payment support

Modifier 57 (inv-07)

Modifier 57 - 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

Applicable settingAllows separate reimbursement for an E/M visit provided on the day prior to or the day of a major surgery (90-day global period) when billed with modifier 57

Reimbursement levelReimbursement for the E/M visit is based on 100% of the applicable fee schedule or contracted/negotiated rate

Review rightsHealth Plan reserves the right to request medical records for review to support payment; failure to use modifier appropriately may result in claim not being accepted

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 25 and 57: Evaluation and Management with Global Procedures

Policy CodePolicy G-06003

Change TypeAdded nonreimbursable rule

Effective DateApr 1, 2026

Next Review Date

Key ActionAppend modifier 25 or 57 when appropriate and document the reason in the medical record; the Health Plan may request records for post-payment review.

SourceLink

On This Page

OpenPayer

Modifiers 25 and 57: Evaluation and Management with Global Procedures

Coverage Criteria for Modifiers 25 and 57

Relevant Modifiers and CPT Codes

Provider Documentation and Post-Payment Review

Modifier Definitions