Why it matters in orthopedics
Fracture care and urgent orthopedic surgery often move fast: a patient is evaluated in the office or emergency department and goes to the operating room the same day or the next morning. Medicare’s global period for a major procedure starts the day before surgery, so without modifier 57 that evaluation is treated as included preoperative care and denied.
Elective cases work differently. When the decision for a joint replacement was made at an earlier visit, the preoperative visit the day before surgery is part of the global surgical package and is not billed separately.
How it works
Medicare pays an E/M on the day of or the day before a procedure with a 90-day global period when modifier 57 shows the visit resulted in the decision to operate (Medicare Claims Processing Manual, Chapter 12, §30.6.6.C and §40.2.A.4).
If the decision visit happens on the day of surgery, bill it with 57, not modifier 25.
Modifier 57 is not used with minor procedures (0- or 10-day global periods). Contractors may not pay an E/M billed with 57 on the day of or the day before such a procedure, because the decision to do a minor procedure is part of the procedure.
Visits after the decision, beginning the day before a major surgery, are included in the global payment.
An E/M two or more days before major surgery falls outside the global period and needs no modifier.
NCCI has no edits for this rule because Medicare contractors run their own (NCCI Policy Manual, Chapter I, Section D, revised January 1, 2026). Contractors that see high modifier 57 use review records case by case, educate the practice and may add prepayment screens.
Situation | Modifier on the E/M |
|---|---|
Separately identifiable E/M on the day of a joint injection (0-day global) | 25 |
Office visit that results in the decision for fracture fixation (90-day global) the next morning | 57 |
Preoperative visit the day before an elective joint replacement decided weeks earlier | None; included in the global payment |
Visit two weeks before surgery where the surgeon recommends the operation | None needed; outside the global period |
Orthopedic example
A 74-year-old patient is seen in the office after a fall with a displaced ankle fracture. The surgeon evaluates the injury, reviews X-rays, discusses options and schedules open reduction and internal fixation for the next morning. The office visit is billed with the appropriate E/M code and modifier 57, because it produced the decision to operate on the day before a major procedure. Confirm in the Physician Fee Schedule Look-Up Tool that the fixation code carries a 090 global indicator.
Common denial triggers
57 appended to an E/M on the day of a 0- or 10-day procedure, such as a joint injection or casting.
57 used on a preoperative history and physical after the decision was made at an earlier visit.
The note does not document that the decision to operate was made at that visit.
Modifier 25 used instead of 57 for a decision visit on the day of a major surgery.
How to prevent or fix
Ask surgeons to document the decision explicitly: the findings, the options discussed and the plan to operate, with the date of the decision.
Check the procedure’s global indicator before choosing between 25 and 57.
Follow commercial rules too. Cigna’s Reimbursement Policy M25 lists using 25 rather than 57 for a major surgery the day of or day after the visit as incorrect, and UnitedHealthcare’s Global Days Policy (2026R0005E) carves out the initial evaluation with 57 only for 90-day procedures.
Our injection-day guide contrasts modifiers 57 and 25 on clinic days.
Frequently asked questions
Can modifier 57 be used when the surgeon decides to do a joint injection?
No. Joint injections are minor procedures with a 0-day global period, and Medicare includes the decision to perform a minor procedure in the procedure’s payment. Contractors may not pay an E/M billed with modifier 57 on the day of or the day before a 0- or 10-day procedure. A separately identifiable E/M on an injection day uses modifier 25 instead.
What if the decision for surgery was made two days before the operation?
Then the visit falls outside the global period, which for a major procedure begins the day before surgery. Bill the E/M without modifier 57, since it is not part of the surgical package. If the surgeon also performs a minor procedure at that visit, such as an injection, a separately identifiable E/M would carry modifier 25.
Does modifier 57 apply when a partner makes the decision?
Yes, if the partner has the same specialty and is in the same group. CMS treats same-specialty physicians in a group practice as one physician for global surgery. If that partner’s visit on the day of or the day before surgery produced the decision to operate, the E/M is billed with modifier 57, just as it would be for the operating surgeon.
Guides that cover this term
Related terms
Sources
Medicare Claims Processing Manual, Chapter 12: Physicians/Nonphysician Practitioners — CMS, Rev. 13753, issued May 7, 2026
Global Surgery (MLN907166) — CMS Medicare Learning Network, December 2025
Medicare NCCI Policy Manual, Chapter I: General Correct Coding Policies — CMS, revision date January 1, 2026
Reimbursement Policy M25: Modifier 25 — Cigna Healthcare, effective April 20, 2009; last updated February 20, 2026
Global Days Policy, Professional (Policy Number 2026R0005E) — UnitedHealthcare Commercial and Individual Exchange, version dated September 20, 2026
This entry is educational and is not legal, coding-compliance or billing advice. Payer rules change often, so confirm requirements with the payer before you bill. CPT® is a registered trademark of the American Medical Association; code descriptions here are Rette’s plain-language summaries.