CurrentUCarePolicy N/A

-57 Decision for Surgery Modifier

This policy governs when UCare will accept and separately pay Evaluation and Management (E/M) services billed with the -57 modifier that result in the initial decision to perform a major (90-day global) surgery, and applies to all UCare products.

Policy Summary

PayerUCare

Policy-57 Decision for Surgery Modifier

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 4, 2025

Key ActionProvide E/M service on the day before or day of a major surgery and append -57; keep documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%payment of UCare base allowed amount for eligible -57 billed services

90-dayglobal surgery period referenced for major surgeries

all productspolicy applies to

day before or day oftiming when -57 may be appended

When UCare Pays for E/M Services with Modifier -57

Payment criteria for -57 modifier

UCare will separately pay for E/M services billed with -57 when the following conditions are met:

All of the following must be met:

ALL of the following

Service is an Evaluation and Management (E/M) service
E/M resulted in the initial decision to perform a major surgical procedure (decision occurred the day of or the day before the surgery)
Service occurred on the day of or the day before a major surgery (major surgery = procedure associated with a 90-day global period)

Policy Summary

PayerUCare

Policy-57 Decision for Surgery Modifier

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 4, 2025

Key ActionProvide E/M service on the day before or day of a major surgery and append -57; keep documentation available upon request.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing, Documentation, and Verification Steps for Providers

Documentation Required

Billing & documentation expectations

UCare will reimburse a separate Evaluation and Management (E/M) service provided the day prior to or the day of a major surgery when the E/M meets criteria for the decision to perform surgery and modifier -57 is appended. While documentation supporting the E/M is not required to be submitted with the claim, it must be maintained in the patient record and made available to UCare upon request.

Applicable when E/M results in the decision for surgery — append -57 to the E/M CPT code
Payment based on 100% of the UCare base allowed amount for eligible services
Do not submit documentation with the claim unless requested; retain in medical record

Billing Rule

Verify global period

Verify the surgical procedure's global period before billing separate E/M services. Use the Medicare Physician Fee Schedule Database (MPFSDB) to determine the global period associated with the CPT code for the procedure; this informs whether a separate preoperative E/M may be payable.

Check MPFSDB for the procedure's global period (0, 10, 90 days, etc.)
If the global period allows a separately payable E/M when modifier -57 is appended, bill accordingly
If unsure, reference the CMS Claims Processing Manual Section 30.6.6 or contact UCare provider services

Key Terms

-57 Decision for Surgery Modifier — define the modifier and its use

Definition-57 Decision for Surgery Modifier: a modifier appended to Evaluation and Management (E/M) services that resulted in the initial decision to perform surgery either the same day of, or the day before, a major surgical procedure (90‑day global)

Permitted useAppend to E/M services that led to the decision to perform major (90‑day global) surgery

Prohibited useDo not append -57 to non‑E/M CPT/HCPCS codes or to surgical procedure codes; not used for minor surgeries

Major surgical procedure — define as procedure associated with a 90-day global period

DefinitionMajor surgical procedure: a procedure associated with a 90‑day global period as defined in the Medicare Physician Fee Schedule Database

VerificationRefer to the Medicare Physician Fee Schedule Database (MPFSDB) to determine the global period for the surgical procedure

Payment implicationWhen an E/M meeting criteria occurs the day of or day before a major surgery and is billed with -57, UCare will separately pay based on 100% of the UCare base allowed amount

OpenPayer

-57 Decision for Surgery Modifier

When UCare Pays for E/M Services with Modifier -57

Modifier and Timing Rules

Billing, Documentation, and Verification Steps for Providers

Key Terms