New vs. Established Patient

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June 9, 2016

Question:
If I see a new patient and during that visit I identify the need for surgery the same day, can I append a Modifier 57 to the E/M service and get paid?

Answer:
You determine during the evaluation that the patient would need surgery the same or next day for a major procedure (90 day global), append Modifier 57 to the E/M service. We are seeing denials from various payers when reporting Modifier 57 particularly when the patient is evaluated in the emergency department. You may need to appeal any claim denials as CPT guidelines allow the use of Modifier 57.

If the procedure is a minor procedure with at 10 day global and the E/M service is significantly separately identifiable, report the E/M service with Modifier 25.

Use caution when appending the 25 Modifier as CMS has indicated that there is an inherent E/M service in every procedure and routine use of Modifier 25 may create payer scrutiny.

*This response is based on the best information available as of 06/09/16.