Modifier 57: Decision for Surgery, and Why It Is Not Modifier 25

Modifier 57 exists to solve one problem: the global surgical package for a major procedure reaches back and swallows the preoperative visit, including the visit at which the surgeon decided to operate. That visit is real work with real cognitive content, and CMS carves it out — but only under conditions that are much narrower than most people apply them, and only for major surgery.

The confusion with modifier 25 is nearly universal and almost always resolves the same way: modifier 57 is a question about major surgery; modifier 25 is a question about minor and XXX procedures. Everything else follows from that.

The Decision Rule

Modifier 57 is correct when all of these hold:

1. The procedure has a 90-day global period. The Claims Processing Manual is explicit: contractors pay for an E/M on the day of or the day before a procedure with a 90-day global surgical period when modifier 57 indicates the service resulted in the decision to perform the procedure — and they may not pay an E/M billed with modifier 57 where the procedure has a 0- or 10-day global period. The NCCI Policy Manual uses the same boundary: a 090 global period defines a major surgical procedure.
2. The E/M occurred on the day of surgery or the day before. Those are the only two days inside a major procedure’s preoperative window. An E/M earlier than that is outside the global package altogether and needs no modifier.
3. That E/M is where the initial decision to operate was made. This is the substantive test and the one that fails most often.
4. The E/M is the surgeon’s own service (or their group’s), such that it would otherwise fall inside the global package.

If the decision to operate was reached at an earlier encounter and the day-before or day-of visit was preoperative preparation, the Claims Processing Manual treats that visit as included in the global payment. Noridian states the consequence plainly: if the decision for surgery was made a week prior, no modifier should be used, and the visit on the day before or day of surgery is part of the global surgical package with no extra allowance.

Why Modifier 57 Does Not Apply to Minor Surgery

This is worth understanding rather than memorising, because it explains the whole 25/57 divide. The Claims Processing Manual gives two reasons. First, the global period for a minor surgery does not include the day prior to the surgery, so there is no preoperative day to carve out. Second, where the decision to perform a minor procedure is typically made immediately before it, that decision is a routine preoperative service — and a visit or consultation is not billable in addition to the procedure.

The NCCI Policy Manual states the same rule from the other direction: for procedures with a 000 or 010 global period, the decision to perform the minor surgical procedure is included in the payment for the procedure and shall not be reported separately as an E/M service. It adds a detail worth holding onto, because it defeats a common argument: the fact that the patient is new to the practice is not, on its own, sufficient to justify reporting an E/M on the same date as a minor surgical procedure.

So the decision-to-operate carve-out is a feature of major surgery only. On a minor procedure, the question is never “did I decide to do this today?” — it is the modifier 25 question: was there a significant, separately identifiable E/M service above and beyond the usual pre- and post-procedure work?

What the Record Must Show

Modifier 57 asserts a causal fact — that this encounter produced the decision — so the note has to show the decision being made, not merely reported.

• The evaluation that led to the decision, in the same note. History, examination and the diagnostic reasoning that resolved the question of whether to operate. A note that opens with “patient here for pre-op” describes preparation, not decision-making.
• An explicit statement that the decision was made at this encounter, ideally with the surgery date and the consent discussion. This costs a sentence and forecloses the most common reviewer objection.
• Evidence that this was the initial decision. If prior notes in the record show the operation already planned, the modifier is not supportable regardless of how much work the day-of visit involved. Where a previously-considered plan genuinely changed — a different procedure, a materially changed clinical picture — say so.
• Independent support for the E/M level billed. Modifier 57 does not validate the level; it only removes the global-package bundling.

The Claims Processing Manual works through the observation-setting cases in useful detail. If an emergency department physician orders hospital outpatient observation and a neurosurgeon is called in, evaluates, and decides the patient requires surgery, the surgeon bills an office or other outpatient visit code with modifier 57 — not an observation code, because a patient receiving hospital outpatient observation services is not an inpatient and only the physician who ordered observation may bill observation care. Where the surgeon is the one who ordered observation and makes the decision during that period, the surgeon bills the observation code with modifier 57. Same clinical event, different code, decided by who ordered observation.

A related example in the same section is a good test of understanding: a surgeon orders observation on postoperative day 80 after a TURP, and during observation decides the patient needs kidney surgery. The observation service is billed with modifier 57 (decision for surgery), and the subsequent kidney procedure is reported with modifier 79 as an unrelated procedure in the postoperative period. Two modifiers, two different questions, one encounter.

The Misuse That Triggers Denials and Audits

1. Modifier 57 on a minor procedure. Contractors are instructed not to pay it where the global period is 0 or 10 days. This is a hard edit, not a judgement call.
2. Modifier 57 on a routine pre-op visit. The single most common substantive error: the surgery was already decided, and the day-before visit was consent, marking, clearance review and instructions. That is global-package work.
3. Modifier 57 as a habit on every day-of E/M. The Claims Processing Manual directs contractors that where a review finds a high usage rate of modifier 57, the contractor must complete a case-by-case record review and educate the provider — and if high usage continues, may impose prepayment screens or documentation requirements. Modifier 57 is explicitly a data-analysis target.
4. Modifier 57 on an E/M unrelated to the surgical diagnosis. Noridian’s guidance excludes this. An unrelated E/M in a postoperative period is a modifier 24 question; an unrelated E/M before surgery is generally not inside the package at all.
5. Modifier 57 by a non-operating physician after a transfer of care. Where the surgeon and another physician have agreed a transfer of care, the other physician’s services related to the surgery are not converted into billable decision-for-surgery visits by the modifier.

Modifier 57 vs. Modifier 25 — The Distinction That Matters

Both modifiers attach to an E/M service performed on the same date as a procedure. They are not alternatives to be weighed; the global period decides which one is even available.

	Modifier 57	Modifier 25
Applies to procedures with	090 global period (major surgery)	000 or 010 global period (minor surgery), or XXX (outside the global concept)
Eligible days	Day of surgery or day before	Same date of service only
The assertion being made	This encounter produced the initial decision to operate	This E/M was significant and separately identifiable from the procedure’s inherent work
Different diagnosis required?	The E/M should relate to the condition being operated on	No — the NCCI Policy Manual states the E/M may be related to the same or a different diagnosis as the procedure
Does deciding to do the procedure justify it?	Yes — that is the entire basis	No — the decision to perform a minor procedure is included in its payment

The last row is the crux, and it is where the two modifiers are exact opposites. For major surgery, the decision is what you are being paid for. For minor surgery, the decision is what you are not being paid for separately, and the E/M has to earn its place on some other basis entirely.

The Claims Processing Manual removes any ambiguity about overlap: if the E/M occurs on the day of surgery, the physician bills using modifier 57, not modifier 25.

Other Nearby Modifiers

Modifier 57 vs. modifier 24

Modifier 57 looks forward at an operation about to happen; modifier 24 looks back at one that already happened and asserts the current visit is unrelated to it. Both concern E/M services caught by a global package, but at opposite ends of it.

Modifier 57 vs. modifier 79

Where a decision-for-surgery visit occurs inside another procedure’s postoperative period — the TURP example above — both modifiers appear on the claim, on different lines: 57 on the E/M, 79 on the unrelated procedure.

Modifier 57 vs. modifier 22

No relationship, but they are sometimes reached for together on a hard case. Modifier 22 is about the difficulty of the operation itself and applies to the procedure code; modifier 57 is about the visit at which the operation was decided and applies to the E/M code.

Where Jurisdiction Matters

The 90-day boundary, the two-day preoperative window and the initial-decision test are national rules from the Claims Processing Manual and the NCCI Policy Manual. What varies by contractor is the operational layer: whether a MAC has imposed prepayment documentation requirements on a specific practice following a utilisation review, how it handles consultation codes and observation scenarios, and how it treats the surgeon’s group and specialty. Noridian, Novitas and First Coast Service Options each publish their own modifier 57 guidance with different worked examples.

Non-Medicare payers frequently follow CPT convention rather than the Medicare 090-only rule, and some accept modifier 57 in circumstances Medicare would not — while others apply stricter prepayment review. Neither the Medicare rule nor another payer’s rule generalises. Where you cannot find a governing statement, the structure of the determination — is this a major procedure, is this within the two-day window, was the decision made here — is what remains stable.

Frequently Asked Questions

Can modifier 57 be used with a minor procedure?

No. Contractors are instructed not to pay an E/M billed with modifier 57 where the procedure has a 0- or 10-day global period. The equivalent question for a minor procedure is a modifier 25 question, and the decision to perform the minor procedure does not by itself support it.

Is modifier 57 only for the day before surgery?

It covers the day of surgery and the day before, which together are the preoperative portion of a 90-day global package. An E/M more than one day before major surgery is outside the package and does not need the modifier.

Does modifier 57 apply if the decision was made two weeks ago?

No. The carve-out is for the encounter producing the initial decision. A day-of or day-before visit for a previously-decided operation is preoperative care included in the global payment.

Does modifier 57 bypass an NCCI edit?

Modifier 57 is listed in the NCCI Policy Manual among the global-surgery NCCI PTP-associated modifiers, so it can bypass an edit whose Correct Coding Modifier Indicator is 1 where clinical circumstances justify it. The manual also notes that NCCI does not itself contain edits based on the decision-for-surgery rule, because MACs maintain separate edits for it — which is why a modifier 57 problem usually surfaces as a MAC denial rather than an NCCI rejection.

Which E/M code should be billed with modifier 57?

Whatever code the encounter actually supports on its own terms — the modifier does not change code selection. In observation settings, the Claims Processing Manual is specific that a patient receiving hospital outpatient observation services is not an inpatient, and only the physician who ordered observation may bill observation care; a consulting surgeon in that setting bills an office or other outpatient visit code with modifier 57.

Related CASRAI Resources

• Modifier 24: unrelated E/M in the postoperative period — the other end of the same global package
• Modifier 22: increased procedural services
• Modifier 51 vs modifier 59
• Modifier 50: bilateral procedures
• Modifier 25: the significant, separately identifiable E/M
• Modifier 59 and the X{EPSU} subset modifiers
• The False Claims Act in billing
• Clinical trial billing compliance checklist

Sources: CMS Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Sections 30.6.6, 30.6.8 and 40.2; CMS National Correct Coding Initiative Policy Manual, Chapter 1, Sections D and E (revision date 1/1/2026); Noridian Healthcare Solutions modifier 57 guidance. CPT is a registered trademark of the American Medical Association; descriptors are summarised here rather than reproduced. General reference material — verify against your MAC’s current guidance and the payer’s own policy.