Modifier 57
Decision for Surgery
E/M resulted in decision for surgery
Important: Modifier usage depends on documentation and payer policy. Never add a modifier without supporting documentation. Always verify payer-specific rules, as modifier policies vary. The information on this page is for educational purposes only and does not guarantee payment. When in doubt, consult the official CPT guidelines, NCCI Policy Manual, and payer-specific policies.
Modifier Description
Modifier 57 indicates that an evaluation and management service resulted in the initial decision to perform surgery. Used on E/M codes on the day before or day of a major surgery (90-day global).
Why This Modifier Exists
Modifier 57 was created to allow billing for the E/M visit that resulted in the decision to perform surgery. Without it, the pre-operative E/M would be bundled into the global surgical package. Modifier 57 specifically applies to surgeries with 90-day global periods — modifier 25 handles 0 and 10-day globals.
Plain English Explanation
If a patient comes in for an E/M visit and the doctor decides "you need surgery," and the surgery happens the next day or that same day, you add modifier 57 to the E/M. This tells the payer "the office visit wasn't pre-op — it was the visit where we decided to do surgery."
When to Use
Use on an E/M code when the E/M service resulted in the decision to perform surgery, and the surgery has a 90-day global period. The E/M must be on the day before or the day of the surgery.
When NOT to Use
Do NOT use for surgeries with 0 or 10-day global periods — use modifier 25 instead. Do NOT use for pre-operative visits that are included in the global package. Do NOT use if the decision for surgery was made during a previous visit.
Documentation Requirements
The medical record must clearly document that the E/M service resulted in the decision to perform surgery. The documentation should show the evaluation that led to the surgical decision, not just pre-operative planning.
Common Denial Reasons
- CO-97 (bundled into global package), CO-16 (missing documentation of surgical decision), CO-50 (not medically necessary), CO-151 (payment adjusted — part of global).
Common Rejection Reasons
- Rejected for using on a 0 or 10-day global surgery (should use 25).
- Rejected for missing documentation of the surgical decision.
- Rejected if the decision was made at a previous visit.
Common Mistakes
- Using it for surgeries with 0 or 10-day global periods (should use 25).
- Using it for routine pre-op visits.
- Not documenting the decision-making.
- Using it when the decision was made previously.
Example Scenarios
Patient presents for knee pain, after evaluation the physician decides surgery is needed, and performs arthroscopy the next day — modifier 57 on the E/M.
Patient seen for abdominal pain, decision made for appendectomy, surgery same day — modifier 57 on the ED E/M.
Payer Considerations
Medicare follows the global surgery rules. The E/M with modifier 57 is separately payable if the surgery has a 90-day global. Some payers have specific modifier 57 policies. Always verify the global period of the surgery code.
Telehealth Considerations
Modifier 57 can be used with telehealth E/M if the decision for surgery was made during a telehealth visit. Combine with modifier 95 as appropriate.
Hospital Considerations
For facility billing, modifier 57 is less common. Hospital E/M before surgery may be covered under different rules. Check OPPS.
Professional Billing Considerations
For professional billing, modifier 57 is critical for getting paid for the E/M that led to a surgical decision. Verify the global period — only use for 90-day globals. Document the decision-making process.
Never Add Without Documentation
Never add modifier 57 to a claim without supporting documentation. Always verify payer-specific rules and consult the official CPT guidelines, NCCI Policy Manual, and payer policies. When in doubt, consult a certified coder or billing specialist.
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