A patient presents with worsening lower back pain after receiving an epidural injection intended to provide relief just one week ago. Upon examination, the provider determines the patient is a candidate for laminectomy at the L5-S1 facet. The provider discusses the procedure, including preoperative instructions and performs a complete physical examination to clear the patient for surgery. Which modifier will be appended to this E/M service?

Question

Quizplus · Accepted Answer

Modifier 57 is used to indicate that the decision for surgery was made during the E/M service provided on the day of or the day before a major surgery. Since the provider decided on a laminectomy, which is a major surgery, during the examination, modifier 57 is appropriate to append to the E/M service code.

A Patient Presents with Worsening Lower Back Pain After Receiving