Urology Coding – Making Sense of Modifiers in 2016

If you are a coder involved in urology coding, it’s imperative to know modifiers inside and out, or your might be risking denials, slashed reimbursement, and fraud charges while filing claims. Lately, the office of the Inspector General (OIG), in its review of the use of modifiers have discovered errors in the use of some of the most commonly used modifiers that have resulted in overpayments to urologists and other providers. In this blog, we would be talking about Modifier -25 and -57 as it is probably the most misunderstood modifiers and there is very slight difference between the two.

When urologist decides to perform surgery after seeing a patient, he can get paid for that initial encounter only by appending a modifier. For coders, it’s confusing whether to use modifier -57 (decision for surgery) or modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

What Is The Difference Between Modifier -25 and -57?

When filing medical billing claims, modifier 25 and 57 are sometimes difficult to differentiate as the difference is slight. Generally, Medicare use modifier -25 on all E/M services associated with minor procedures, meaning the evaluation and management should be paid for separately and not bundled with the surgical reimbursement. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

Use modifier -57 for an E/M service, when a physician decides a MAJOR surgical procedure needs to be done on the same day or the day after. This, like modifier 25, requires separate reimbursement for the E&M and for the surgery. As the difference is very slight between these two modifiers for medical billing, modifier 25 is used in medical billing for minor procedures, while modifier 57 is used in medical billing for major procedures. Additionally, another small difference is that modifier 57 could mean the surgery will be done the next day, whereas medically billing modifier 25 means the surgery will be done on the same day only.

When Not to Use the Modifier 25

  1. When billing for services performed during a postoperative period if related to the previous surgery
  2. When there is only an E/M service performed during the office visit (no procedure done)
  3. When on any E/M on the day a “Major” (90 day global) procedure is being performed
  4. When a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have “inherent” E/M service included.
  5. When a patient came in for a scheduled procedure only

When Not To Use the Modifier 57

  • When appending to a surgical procedure code
  • When an E/M procedure code is performed the same day as a minor surgery. When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure.
  • When a patient came in for a preplanned or prescheduled surgery
  • Do not report on the day of surgery if the surgical procedure indicates performance in multiple sessions or stages

The CMS has already increased the surveillance of the use of all modifiers, if you are confused about appending modifier in Urology, join Urology coding expert Michael A. Ferragamo, Jr., MD, FACS  in this informative session,


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