Q: Modifiers 25 and 57 are interchangeable. It just depends on the place of service as to which one should be used. True or False?

A: There are very different reasons for using each of these modifiers. Both are used in any setting as long as the other requirements have been appropriately met within the documentation.

If a patient comes in for a visit, there might be other services ordered at that time that can be performed during the visit. With appropriate documentation supporting medical necessity, the services could all be reported when the coding guidelines are followed. The most important thing to keep in mind is that the note must separately substantiate each reported service. 

If, during that visit, the physician or non-physician practitioner determines that the patient might benefit from receiving an additional service such as an injection, therapy or a simple procedure, it is important to report this activity along with the evaluation and management (E/M) visit code. 

The two most important factors to consider are the documentation and the most appropriate code choices. The medical record documentation should clearly illustrate that the E/M service was significant and separately identifiable from the additional service performed.

Modifier 25 is often the most appropriate modifier for these situations. It is appended to the E/M service showing that the visit was significant and clearly separate from the procedure performed. Another potential modifier is modifier 57. Both of these modifiers have very specific definitions and are used for very different reasons. 

The one characteristic these two modifiers share is that they are only appended to the E/M service. One distinction between these two modifiers is that modifier 57 is only appended to major procedures (those with a 90-day global period associated with them) and never to minor procedures. Modifier 25 should be considered for use for those types of procedures.

The physician’s documentation should clearly explain the details of both the procedure as well as the visit. If the visit is distinct and separately identifiable with clear medical decision making (MDM) demonstrating the need to perform the procedure the same day, modifier 25 should be used. If the major surgical procedure is illustrated within the MDM as needed that day or the next, and the documentation of the visit supports a level of E/M service, modifier 57 would be appended and reported along with the CPT code for the surgery.