Modifier 57; Decision for Surgery

Policy No: 104
Originally Created: 11/01/2008
Section: Modifiers
Last Reviewed: 04/01/2023
Last Revised: 04/01/2018
Approved: 04/13/2023
Effective Date: 05/01/2023
Policy applies to: Group and Individual & Medicare Advantage

This policy applies only to physicians and other qualified health care professionals.

Modifier 57
Current Procedural Terminology (CPT®) Modifier 57 a two position numeric code appended to an Evaluation and Management (E&M) code when provided on the day before or the day of a Major Procedure.

Major Procedure
Surgical procedures with a 1-day preoperative period and 90 day postoperative period.

Minor Procedure
Surgical procedures with a 0 or 10 day postoperative period.

An E&M service provided the day before or the day of a Major Procedure that resulted in the initial decision to perform surgery is eligible for reimbursement if modifier 57 is appended to the E&M code.

Modifier 57 should not be used when the E&M service is associated with a Minor Procedure.

Modifier 57 should not be used when the E&M service was for the preoperative evaluation (when the decision to perform surgery has already been made and the purpose of the exam is a "pre-op visit" to evaluate the current medical status of a patient before a scheduled surgical procedure).

The submission of modifier 57 appended to an E&M procedure code indicates that documentation is available in the patient's records confirming that the E&M service resulted in the initial decision to perform the surgery.

American Medical Association. Appendix A: Modifiers CPT. AMA Press

National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, current version Chapter 1

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