CurrentMolina HealthcarePolicy N/A

Global surgical package and modifier -57 reimbursement guidance

Governs reimbursement and billing rules for E&M services related to surgical decisions (major and minor surgeries) for Molina Healthcare providers; specifies use of modifier -57 and documentation expectations. Affects Molina providers and claims processing, with a state exception noted for Michigan.

Policy Summary

PayerMolina Healthcare

PolicyGlobal surgical package and modifier -57 reimbursement guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateAug 1, 2025

Key ActionAppend modifier -57 to an E&M when the decision for major surgery is made the day before or the day of surgery and ensure documentation supports both the E&M and the procedure(s).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90-daypost-operative global period for major surgery

10-day or 0-daypost-operative global period values for minor surgery (010 or 000)

MIstate explicitly exempt from this policy

3documented revision entries shown in history

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E&M and global surgery coverage criteria

Rules for billing E&M services in relation to surgical global periods and when to apply modifier -57:

Providers must differentiate between an E&M billed for a decision for surgery (reimbursable) and an E&M billed for a pre‑operative visit (included in the surgical package); use modifier -57 to indicate the decision for surgery.

Per CMS definition of the surgical package (major vs minor) and use of modifier -57.

Definitions: Major surgery = procedures with a 090 (90‑day) postoperative global period; Minor surgery = procedures with 000 (0‑day) or 010 (10‑day) postoperative global period in the CMS NPFS 'Global Surgery' field.

Used to determine when modifier -57 applies.

If the decision for major surgery is made the day before or the day of the major surgery, the E&M billed for that decision must have modifier -57 appended.

Modifier -57 distinguishes a reimbursable decision for surgery from routine preoperative services.

Decisions for minor procedures made immediately before the service are considered routine preoperative services; a visit or consultation may not be billed in addition to the procedure.

Do not bill a separate E&M for minor procedures decided immediately prior to the procedure.

When both major and minor procedures occur in the same episode and the decision for surgery is made the day before or the day of, append modifier -57 to the E&M to reflect the decision for the major surgery; documentation must support both the E&M and the procedure(s).

Documentation must be sufficient to support claims for both the E&M and the procedure(s).

Modifier 57 and Billing Actions

Billing Rule

Modifier -57 and related billing/documentation actions

Append modifier -57 to the E&M when the decision for major surgery is made the day before or the day of the major surgery; do not bill a separate visit or consultation for minor procedures that are decided immediately before the service. When both major and minor procedures occur in the same episode and the decision for surgery is made the day before or day of surgery, append modifier -57 to the E&M to reflect the decision for the major surgery and ensure the medically necessary E&M and the procedure(s) are appropriately and sufficiently documented in the patient's medical record to support the claim.

Append modifier -57 to E&M for decisions made the day before or day of major surgery.
Do not bill a separate preoperative E&M for minor procedures typically decided immediately before the service.
When major and minor procedures occur in the same episode, append -57 to reflect the major surgery decision and document both the E&M and procedures sufficiently.

Policy Summary

PayerMolina Healthcare

PolicyGlobal surgical package and modifier -57 reimbursement guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateAug 1, 2025

Key ActionAppend modifier -57 to an E&M when the decision for major surgery is made the day before or the day of surgery and ensure documentation supports both the E&M and the procedure(s).

SourceLink

On This Page

OpenPayer

Global surgical package and modifier -57 reimbursement guidance

E&M and Global Surgery Coverage Criteria

Coding Guidance and Disclaimer

Modifier 57 and Billing Actions

Definitions