Modifier 24 – Unrelated E/M Service During a Postoperative Period

What This Means 

Modifier 24 says:

“Yes, the patient is in a post-op period — but this visit had nothing to do with the surgery.”

It allows an E/M service to be paid during the global period only if the reason for the visit is completely unrelated to the surgery.

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When to Use Modifier 24

Use Modifier 24 only when all of the following are true:

• The patient is in a postoperative (global) period

• The same physician (or same specialty/group) performed the surgery

• The E/M visit is for a different condition

• The documentation clearly supports that separation​

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Example – Correct Use

A patient had knee surgery and is in the global period.
They return for evaluation of acute bronchitis.

✔ The visit is unrelated
✔ Modifier 24 is appropriate

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When NOT to Use Modifier 24

Do not use Modifier 24 if:

• The visit is for routine post-op care

• The visit addresses complications or expected healing

• The problem is related to the surgical site or recovery

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Example – Incorrect Use

A patient returns for increased pain and swelling at the surgical site.

✖ This is post-op care
✖ Modifier 24 should not be used

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Documentation Tips

• Clearly document the unrelated diagnosis

• Avoid linking the complaint to the surgery

• Keep post-op language out of the note

• Separate assessment and plan for the unrelated condition

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What This Tells the Insurance Company

“This visit is not included in the surgical package and deserves separate payment.”

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Modifier 25 – Significant, Separately Identifiable E/M Service (Same Day)

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What This Means

Modifier 25 says:

“Yes, a procedure was done — but the E/M visit went above and beyond what’s normally included.”

This modifier is about same-day E/M services and minor procedures.

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When to Use Modifier 25

Use Modifier 25 when:

• An E/M service and a procedure occur on the same day

• The E/M is medically necessary

• The E/M is more than the work inherent to the procedure

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Example – Correct Use

A patient presents with abdominal pain.
A full evaluation is performed, and a minor procedure is done.

✔ The E/M addressed decision-making
✔ Modifier 25 is appropriate

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When NOT to Use Modifier 25

Do not use Modifier 25 if:

• The visit only supports performing the procedure

• The documentation shows minimal assessment

• The E/M is bundled into the procedure

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Example – Incorrect Use

A patient arrives solely for a scheduled injection with no additional evaluation.

✖ No separate E/M work
✖ Modifier 25 should not be used

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Documentation Tips

• Document why the E/M was necessary

• Show separate history, exam, or medical decision-making

• Avoid “procedure-only” notes

• Diagnosis for the E/M should stand on its own when possible

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What This Tells the Insurance Company

“This wasn’t just a procedure visit  additional physician work occurred.”

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Modifier 57 – Decision for Surgery

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What This Means 

Modifier 57 says:

“This visit is where the decision was made to perform major surgery.”

It applies only to major surgeries (90-day global period).

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When to Use Modifier 57

Use Modifier 57 when:

• The E/M visit results in the initial decision to perform major surgery

• The surgery is scheduled for the same day or a future date

• The visit is not pre-operative clearance

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Example – Correct Use

A patient is evaluated for severe abdominal pain.
The provider determines surgery is required.

✔ Decision made during the E/M
✔ Modifier 57 is appropriate

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When NOT to Use Modifier 57

Do not use Modifier 57 if:

• The decision for surgery was already made previously

• The visit is pre-op testing or clearance

• The procedure is minor (use Modifier 25 instead)

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Example – Incorrect Use

A patient returns for surgical consent after the decision was already documented.

✖ No new decision
✖ Modifier 57 should not be used

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Documentation Tips

• Clearly state decision for surgery

• Include rationale and clinical findings

• Document that this is the initial decision

• Avoid vague language like “discussed surgery”

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What This Tells the Insurance Company

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“This visit led directly to surgery and is not part of the global package.”

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Why These Modifiers Matter 

These modifiers don’t just affect payment — they communicate intent.

Insurance companies aren’t asking:

“Did you perform a visit?”

They’re asking:

“Why should we pay for this visit separately?”

Understanding and documenting that “why” is the difference between:

• Clean claims

• Repeated denials

• Audit risk