Modifier 57- Decision for Surgery

Modifier 57 is used when an evaluation and management service results in the initial decision to perform a major surgery.

What Is Modifier 57?

Modifier 57 is used when an evaluation and management (E/M) service results in the initial decision to perform major surgery.

Under Medicare rules, major surgery generally refers to a procedure with a 90-day global period. When the decision for that surgery is made during an E/M encounter on the day before or the day of surgery, the E/M service may be separately reported with Modifier 57.

Without Modifier 57, the payer may consider the E/M service part of the routine preoperative work included in the global surgical package.

Modifier 57 is appended to the E/M code, not the surgical procedure code. CMS's 2026 NCCI guidance continues to recognize Modifier 57 as a global surgery modifier.

When to Use Modifier 57

Initial Decision for Surgery: The E/M encounter results in the first decision to proceed with major surgery.

Major Surgery: The planned procedure has a 90-day Medicare global period.

Day Before Surgery: The qualifying E/M service occurs one day before the major surgery.

Same-Day Decision: The qualifying E/M service and major surgery occur on the same date.

Separate E/M Service: The encounter represents the evaluation that led to the surgical decision rather than routine preoperative care.

Documentation Supports the Decision: The medical record clearly establishes that the provider evaluated the patient and decided during the encounter that surgery was necessary.

When NOT to Use Modifier 57

Minor Surgery: Medicare does not recognize Modifier 57 for the decision to perform procedures with 000- or 010-day global periods.

Decision Was Previously Made: Do not use Modifier 57 for a routine preoperative visit after the decision for surgery has already been established.

Routine Preoperative Care: Services ordinarily included in preparing the patient for surgery are not separately reportable simply by adding Modifier 57.

Postoperative E/M Service: Modifier 57 does not identify E/M services performed during the postoperative period.

Same-Day Minor Procedure: Modifier 25 may be appropriate when a significant, separately identifiable E/M service is performed on the same day as a minor procedure and its requirements are met.

Surgical Procedure Code: Modifier 57 belongs on the qualifying E/M service, not on the surgery code.

Billing Example

A patient presents to a surgeon with worsening symptoms from a condition that may require operative treatment.

The surgeon performs a medically necessary E/M service, reviews the patient's condition and available diagnostic information, and determines during the encounter that major surgery is necessary.

The surgery is scheduled for the following day.

Because the E/M service resulted in the initial decision to perform major surgery, the appropriate E/M code is reported with Modifier 57.

The surgical procedure is reported separately without Modifier 57.

Documentation Requirements

Reason for Encounter: Document the condition or symptoms that required evaluation.

Clinical Evaluation: Record the relevant history, examination, medical decision-making, or other elements supporting the E/M service.

Decision for Surgery: Clearly document that the decision to proceed with surgery was made during the encounter.

Surgical Procedure: Identify the planned procedure when appropriate.

Medical Necessity: Documentation should support why surgery was medically necessary.

Timing: The record should establish the relationship between the E/M encounter and the subsequent major surgery.

Billing and Claim Considerations

Modifier 57 is closely tied to Medicare's global surgery rules.

CMS does not include an E/M service that results in the initial decision for major surgery in the global surgical payment when that decision occurs on the day before or the day of surgery. The qualifying E/M service can therefore be separately billed with Modifier 57.

The rule is different for minor procedures. CMS considers the decision to perform a minor procedure immediately before the service part of the routine preoperative work. Medicare contractors may deny an E/M service reported with Modifier 57 when the associated procedure has a 000- or 010-day global period.

Providers should also verify the global-period indicator for the surgical procedure rather than assuming that a procedure qualifies as major based solely on its clinical complexity.

Common Billing Mistakes

Using Modifier 57 With Minor Surgery: Medicare limits its decision-for-surgery use to major procedures with a 90-day global period.

Decision Was Already Made: A later routine preoperative visit does not qualify simply because it occurs shortly before surgery.

Appending Modifier 57 to the Surgery: The modifier belongs on the qualifying E/M code.

Confusing Modifier 57 With 25: Modifier 25 addresses a significant, separately identifiable same-day E/M service, while Modifier 57 specifically identifies the initial decision for major surgery.

Routine Preoperative Visit: Preoperative work performed after the surgical decision generally does not qualify.

Insufficient Documentation: The medical record does not demonstrate that the encounter resulted in the decision for surgery.

Common Denial Reasons

Minor Procedure: The associated surgery has a 000- or 010-day global period.

Decision Was Previously Made: Documentation indicates that surgery had already been planned before the E/M encounter.

E/M Included in Global Package: The payer determines that the service represents routine preoperative care.

Documentation Does Not Support Decision: The record fails to establish that the encounter resulted in the initial surgical decision.

Incorrect Modifier Placement: Modifier 57 was reported on the procedure rather than the E/M service.

E/M Service Not Supported: Documentation does not support the medical necessity or level of the E/M service reported.

Modifier 57 vs. Modifier 25

Modifier 57: Identifies an E/M service that results in the initial decision to perform major surgery.

Modifier 25: Identifies a significant, separately identifiable E/M service performed on the same day as another procedure or service.

For Medicare, the critical distinction is the global period of the procedure and purpose of the E/M service. Modifier 57 applies to the decision for major surgery, while Modifier 25 is commonly relevant to separately identifiable E/M work associated with minor procedures.

Modifier 57 vs. Modifier 24

Modifier 57: Identifies the E/M service that results in the initial decision to perform major surgery.

Modifier 24: Identifies an unrelated E/M service performed during the postoperative period of a previous procedure.

Modifier 57 concerns the decision leading to surgery, while Modifier 24 concerns an unrelated encounter during an existing postoperative global period.

Frequently Asked Questions

Can Modifier 57 be used with a minor procedure?
No under Medicare's global surgery rules. CMS states that Modifier 57 should not be used with minor surgeries carrying 000- or 010-day global periods.

Can Modifier 57 be used the day before major surgery?
Yes. When the E/M service on the day before major surgery results in the initial decision to perform that surgery, Medicare allows the E/M service to be separately reported with Modifier 57.