Awareness : Did You Know? 2015-2016

Did You Know? Weekly Educational Series 41

For the Week of August 1, 2016

Modifier 57

This modifier is the easiest to understand. Modifier 57 is only used when a major surgery is planned. Although CPT does not specify, Medicare considers modifier 57 to apply to the office visit when deciding to perform a major surgery, and nearly all payers agree. In this case, “major” or “minor” is defined solely by the payer’s global period designation. Major surgeries generally have a 90-day post-operative period, although in some rare state Medicaid programs some eye surgeries with a 30-day period and would still be considered “major” surgery.

Example: A patient presents for an office visit with increasing flashes and floaters in the right eye for the past few days. On exam, the Ophthalmologist discovers a retinal tear and immediate laser surgery is indicated. If the laser surgery (all retina lasers carry the designated 90-day post-operative global period) is scheduled today or tomorrow, append modifier 57 to the office visit code which shows that the Ophthalmologist decided on the major surgery at this visit. Modifier 57 informs the payer that payment for the exam on the day of and it’s appropriate in addition to the laser code.  Leaving off modifier 57 tells the payer that the physician did not decide on that day ; they will bundle the exam and pay only for the laser procedure.