CurrentBlue Cross Blue Shield - MainePolicy G-06003

Modifiers 25 and 57 reimbursement

Policy governs separate reimbursement rules for Evaluation & Management (E&M) services billed with modifier 25 or modifier 57 when provided on the same day or day prior to procedures, for AMH Health/Blue Cross Blue Shield - Maine provider billing.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 25 and 57 reimbursement

Policy CodePolicy G-06003

Change TypeRevised (combined policies)

Effective DateApr 27, 2022

Next Review Date

Key ActionDocument clearly why the E&M was significant and separately identifiable (or that it resulted in the decision for major surgery) and ensure the medical record supports the billed level of E&M; AMH Health may request records and deny or recoup payment if documentation does not support separate reimbursement.

SourceLink

POLICY UPDATE CHANGES

Combined prior separate policies for Modifier 57 (Decision for surgery) and Modifier 25 (Significant, separately identifiable E&M) into a single policy G-06003 and renamed it Modifiers 25 and 57.

100%Reimbursement rate when modifiers 25 or 57 criteria met

90-dayGlobal period considered a major surgery

0-day or 10-dayGlobal periods considered minor surgery

Reimbursement Criteria for Modifiers 25 and 57

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Modifier 25 reimbursement criteria

Covered when ALL of the following are met:

ALL of the following

Modifier 25 is appended to the E&M service to indicate it is above and beyond the other service or procedure (including usual pre/postoperative care).
The appropriate level of E&M service is billed.
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 57 reimbursement criteria

Covered when ALL of the following are met:

ALL of the following

E&M visit occurs on the day prior to or the day of a major surgery (90-day global period).
Modifier 57 is appended to indicate the E&M visit resulted in the initial decision to perform the major surgical procedure.

Key Thresholds

Major surgery global period90-day

Minor surgery global periods0-day or 10-day

Documentation, Billing Rules, and Review Risks

Documentation Required

Support for modifier 25

Document clearly why the E&M was significant and separately identifiable beyond usual pre/postoperative care and record the level of E&M billed; the medical record must substantiate the billed code.

Documentation Required

Support for modifier 57

Document that the E&M visit resulted in the initial decision to perform a major surgical procedure; AMH Health may request medical records to support payment.

Billing Rule

Modifier usage restrictions

Do not bill modifier 57 for E&M visits associated with minor surgeries (0- or 10-day global periods) or for non‑E&M CPT codes; incorrect use of these modifiers may result in denial or recoupment.

57
25
Potential denial or recoupment for incorrect use

Denial Risk

Post-payment review and recoupment

AMH Health reserves the right to perform post-payment reviews, request medical records, deny claims, or recoup payments if modifiers are used incorrectly or documentation does not support separate reimbursement.

Policy Scope and Operational Notes

This policy governs separate reimbursement for Evaluation & Management (E&M) services billed with Modifier 25 or Modifier 57 for providers billing AMH Health/Blue Cross Blue Shield - Maine. It applies when an E&M is provided on the same day as a procedure (Modifier 25) or on the day prior to or day of a major surgery when the E&M visit results in the initial decision to perform the surgery (Modifier 57).

When the stated criteria are met, reimbursement is 100% of the applicable fee schedule or contracted/negotiated rate for the separately identifiable E&M service. Providers must follow member-specific authorization and medical necessity requirements, and standard correct coding practices apply.

For Modifier 25, documentation must show the E&M was significant and separately identifiable from the procedure (including usual preoperative and postoperative care), the appropriate E&M level was billed, and the reason for the E&M is clearly documented in the medical record. For Modifier 57, documentation must establish that the E&M visit resulted in the initial decision to perform a major surgical procedure (the 90-day global period).

AMH Health may request medical records, perform post-payment reviews, deny claims, or recoup payments if modifiers are used incorrectly or documentation does not support separate reimbursement. Providers should bill only appropriate E&M CPT codes with the modifier and adhere to all billing and submission guidelines.

Defined Terms

Policy Definitions

Modifier 25Used 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; must be supported by documentation meeting E&M reporting criteria.

Modifier 57Used to indicate an E&M service that resulted in the initial decision to perform a surgery on the day prior to or day of a major procedure.

Policy Changes

2022-04-27revisedLatest

Combined prior separate policies for Modifier 57 (Decision for surgery) and Modifier 25 (Significant, separately identifiable E&M) into a single policy G-06003 and renamed it Modifiers 25 and 57; review approved 04/27/2022 (effective 04/27/2022).

2020-01-01initial approval/effective date

Initial approval and effective date of the prior policy (01/01/2020).

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 25 and 57 reimbursement

Policy CodePolicy G-06003

Change TypeRevised (combined policies)

Effective DateApr 27, 2022

Next Review Date

SourceLink

On This Page

OpenPayer

Modifiers 25 and 57 reimbursement

Reimbursement Criteria for Modifiers 25 and 57

Referenced Modifiers and Coding

Documentation, Billing Rules, and Review Risks

Policy Scope and Operational Notes

Defined Terms

Policy Changes

25	Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.
57	Decision for surgery — E&M service that resulted in the initial decision to perform surgery (day of or day prior for major surgery).

Modifiers 25 and 57 reimbursement

Reimbursement Criteria for Modifiers 25 and 57

Referenced Modifiers and Coding

Documentation, Billing Rules, and Review Risks

Policy Scope and Operational Notes

Defined Terms

Cross-Referenced Policies

Policy Changes