Modifier 57 (Decision for Surgery)
Defines when Premera recognizes Modifier 57 on professional claims (CMS-1500/837P) to indicate an E/M resulted in the initial decision for a major procedure; applies to Premera and affiliated lines of business.
Clarified the Purpose statement to indicate that the policy pertains to Professional services billed on a CMS-1500 or 837P claim forms.
Added identification of how minor and major surgery codes are determined and provided a link to the CMS National Physician Fee Schedule.
Minor clarification in second paragraph of the Policy regarding timing/definition of preoperative period for major surgery.
Modifier 57 Coverage Criteria
Modifier 57 coverage criteria
Covered when ALL of the following are met:
ALL of the following
- Modifier 57 may be appended to an Evaluation and Management (E/M) service when that E/M resulted in the initial decision for a major procedure (90-day global period).
- The E/M resulting in the decision for surgery may occur the day before or the day of the major procedure.
- Documentation of the decision for surgery must be present in the medical record and available upon request.
Do NOT append Modifier 57 when any of the following apply
- The E/M is performed on the same day as a minor procedure (0- or 10-day global period), because the E/M is considered part of the preoperative care and bundled into the minor procedure global fee.