Ask An Advisor: Making sense of Modifier 25 and Modifier 57 denials

In this episode of MGMA’s Ask An Advisor podcast, senior industry advisor Cristy Good, MPH, MBA, CPC, CMPE, starts off by sharing an exciting update about how members can get their questions answered through mgma.com following the recent relaunch of the website.

As you browse throughout the entire MGMA website, you can find a green “Ask MGMA” button on the lower right corner of your screen. With a click of the Ask MGMA button, you can submit a question for any area of MGMA staff and subject-matter experts (SMEs) to respond, whether it’s:

• Inquiries for our Service Center about your membership;
• Questions about health policy and regulations answered by the MGMA Government Affairs staff in Washington, D.C.; or
• Your biggest issues in practice management, as researched and answered by SMEs such as Good.

One of the frequently occurring questions sent by MGMA members to Ask An Advisor is how to handle proper coding and billing while using Modifier 25 and Modifier 57, as many practices have reported more denials for claims with these modifiers attached.

In a new member-exclusive article, Good defines the proper uses of Modifier 25 and Modifier 57, with practical scenarios of their applications for evaluation and management (E/M) services in specialties such as OB/GYN, cardiology and primary care.

Uses of the modifiers

• Use Modifier 25 to signify that a significant, separately identifiable E/M service was performed by the same healthcare provider on the same day as another procedure or service. Procedures with a zero-day or 10-day global period can be separately reported by using Modifier 25, assuming the E/M service is significant and separately identifiable. When the patient presents with the knowledge that the procedure is going to be done and no other conditions are addressed, the E/M is typically not supported, and Modifier 25 cannot be used.
• Use Modifier 57 when an E/M service leads to the decision to perform surgery. It is appended to the E/M code to indicate that the decision-making process resulted in a major surgical procedure.

These modifiers can be used separately, though Good also details certain situations in which both can be used together to accurately represent the services provided. The article also outlines common misuses of each modifier for practices to avoid.

Good recommends that practice leaders evaluate the reasons provided for claim denials to assess if it’s related to modifier misuse or other reasons, and then working those denials. “Make sure that your documentation provides clear support for the use of those modifiers. You need to outline the distinct services provided, and the decision-making process involved,” Good said. “When you have accurate and thorough documentation, that's usually what helps you avoid those denials or any audit concerns. … Modifiers 25 and 57 are very valuable to medical billing, and coding so that you can show that you did separate services from your E/M visit, so it's very important to know when to use them and how to use them correctly.”

MGMA members can also use the 2023 Medical Coding and Billing Toolkit for exclusive tools for calculating facility and non-facility reimbursement for the Medicare Physician Fee Schedule, as well as evaluate the latest CPT® and ICD-10-CM code changes and calculate wRVU variance from previous years.

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