Article - Brush Up on Three Modifiers to Increase Reimbursements

When used appropriately, coding modifiers help practices code appropriately and collect revenue to which they’re entitled. The key here is ‘when used appropriately.’ Just because a modifier could technically apply, doesn’t mean that one is warranted. You still have to review the documentation to make sure it supports the requirements for adding the modifier.

Modifier-59 (Distinct Procedural Service)

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used?


·   Check the NCCI edits before appending the modifier. Modifier-59 only applies when NCCI edits indicate that a modifier is allowed. In some cases, a modifier is either not allowed or not applicable.

·  Identify supporting documentation. Only append modifier-59 when physician documentation supports a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury.

·   Append modifier-59 to CPT codes. It doesn’t apply to E/M codes.

·   Think of modifier-59 as a 'last resort'. Only append it when no other modifier (e.g., -RT or -LT) is more appropriate.

Modifier-25 (Same Physician, Same Day E/M Services)

Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or another service) is the most important modifier for pediatricians in Current Procedural Terminology (CPT). It creates the opportunity to capture physician work done when separate E/M services are provided at the time of another E/M visit or procedural service. This allows for more efficient use of your time and may save the patient another visit. However, the use of this modifier has been associated with frustration because many payers, including Medicaid, do not recognize it. The landscape is now changing, with many major payers facing the pressure of successful class-action lawsuits requiring them to recognize and follow CPT guidelines, including modifier 25.


·   Identify the global period for the procedure or service that was rendered. For example, some procedures have a zero-day global period, meaning coders can bill an E/M service on the same date of service when it goes beyond the usual pre-operative and post-operative care associated with the procedure. Modifier-25 is not a pre-requisite for payment. When appropriately documented, E/M services provided on the same day as a procedure with a 90-day global period require a modifier-57 as a pre-requisite for payment.

·   Review physician documentation. Only append modifier-25 when the physician documents that a separately reportable E/M service was provided on the same date of service as a procedure. The E/M service must be above and beyond the usual pre- and post-operative work of a procedure with a global fee period performed on the same day as the E/M service.

·  Think ‘same physician, same day.’ The same physician must perform both the separately identifiable E/M and the other procedure or service within a global fee period.

Modifier-24: Reporting Unrelated E/M Services

Modifier 24 identifies instances in which the same physician performs an E/M service that’s unrelated to a procedure during its global period. This modifier helps physicians get paid for services that are not related to the postoperative care of the procedure.


·   Think ‘unrelated’ before appending this modifier. For example, a patient undergoes gallbladder surgery and follows up with his general surgeon within three days. Coders cannot append modifier-24 to the E/M visit for separate payment. The E/M should not be reported at all because the service is included in the global period for the procedure. If, however, the patient finds a lump in her breast and must return within the post-operative period for evaluation of that lump, a coder can report the E/M visit for the breast lump separately using a modifier-24.

·   Beware of surgical complications. Complications are almost always related to the procedure, in which case any E/M services provided to treat those conditions are not separately reportable within the global fee period.

·   Know what constitutes ‘same physician.’ This modifier applies to the same specialty group—not necessarily the same individual physician.

·  Know when to append more than one modifier. For example, append modifiers -24 and -25 when the E/M is significant, separately identifiable, and unrelated during the global period.

Misusing these three modifiers or any other modifiers can cause a payer to deny your claim altogether. Avoid claim issues by making sure to always use it properly. You can take assistance from medical billing company like Medical Billers and Coders (MBC). With assistance from our expert coders you don’t have to worry about using exact modifiers. To know more about our coding services you can contact us at 888-357-3226/

Published By - Medical Billers and Coders
Published Date - Feb-13-2020 Back

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