One of the most frequent errors can result from the submission of invalid modifier combinations. In addition to the accurate coding of treatment, medical claims must be billed in combination with codes for additional services performed in the office, the corresponding modifiers, if necessary, and ICD-10 or diagnosis codes. The most commonly used wrong modifier combination is of modifier 24 and 25.
Modifier 24 refers to the evaluation and management services provided to the patient on the day of a surgical procedure unrelated to the procedure itself. Modifier 25 identifies the evaluation and management services as unique services provided on the same day by the same medical professional. Understanding the global period for procedures is a key element in assigning modifiers 24 and 25. Global periods are typically zero, 10, or 90 days after the procedure and may include additional preoperative days.
- For doctors of optometry, modifier 24 is most often used when the doctor is providing co-management services.
- Modifier 24 is defined as an “unrelated evaluation and management service by the same physician during the postoperative period.” This means if a patient has surgery and has a condition that requires an evaluation that is completely separate from anything related to the surgery, evaluation, and management (E/M) service would be reported and modifier 24 would be appended.
- Modifier 24 is often reported by doctors of optometry in cases in which the patient experiences an eye problem in the eye that was not operated on, or when the patient has an eye problem in the operated eye that is located in the region of the eye that was not impacted by the surgery.
- This modifier should only be used with E/M services.
- It is critical that documentation should include the specific reason why the visit that occurred during the postoperative period was not related to the surgery.
Correct Use of Modifier 24
A 4-year-old patient is seen in the physician’s office with a 2.5-cm laceration to the right anterior side of the wrist, on which an intermediate layered closure was performed five days ago (CPT code 12031). The patient presents to the physician’s office today complaining of bilateral ear pain. The patient’s mother states he was up all night crying. The physician performs an expanded problem-focused history and examination. The final diagnosis is bilateral otitis media. The provider prescribes amoxicillin and instructs the mother to bring the patient back in seven days to recheck his ears.
The coder correctly assigns the following CPT code to this scenario: 99213-24 Office Outpatient Visit, established patient, expanded problem-focused history; expanded problem-focused physical; medical decision making of low complexity.
Wrong Use of Modifier 24
A 4-year-old patient was seen in the physician’s office five days ago with a 2.5-cm laceration to the right anterior side of the wrist, on which an intermediate layered closure was performed (CPT code 12031). The same patient now presents with redness, swelling, and drainage to the sutured area. The final diagnosis was infected laceration.
The coder correctly assigns the following CPT code to this scenario: 99024 Postoperative Follow-Up Visit, Included Surgical Package, E&M Performed. The modifier is not used because all services are included under the code assigned.
- Modifier 25 is officially defined as “a significant evaluation and management service by the same physician on date of the global procedure.” This means if E/M services are provided that exceed what is normally involved in preparing a patient for a procedure and the standard follow-up services directly following a procedure, then an E/M service should be reported along with modifier 25.
- Reporting modifier 25 may be necessary in certain cases when removing a foreign body or closing a punctum with a punctual plug.
- It’s important to recognize that many E/M services are provided as a standard part of performing surgical services. For example, during a foreign body removal, obtaining the patient’s ocular and general medical history; performing an external exam; evaluating distance vision, and a slit lamp examination would all be standard procedures performed prior to the foreign body removal.
- However, it is possible for additional E/M services to be necessary when performing surgical services. For example, if a patient presented for treatment of glaucoma, and in the course of treating the patient the doctor identified a foreign body, the evaluation for glaucoma and the foreign body removal would be reported. The E/M would be reported with modifier 25.
- Modifier 25 should only be used when reporting E/M services.
- Documentation must reflect the necessity of the E/M service.
- Doctors of optometry should be aware that an E/M service that is provided on the day of the procedure with a global fee period will only be reimbursed if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre-and postoperative work of the procedure.
Correct Use of Modifier 25
Modifier 25 is used to report surgical procedures, labs, X-rays, and supply codes that the physician documents as a separately identified E&M service performed on the same day as another procedure. The E&M service may be prompted by the symptom or condition for which the procedure and/or service was provided. In a situation where a patient presents to the office and a procedure was not anticipated, the E&M can be assigned with the modifier 25.
A patient presents to the emergency department with a chief complaint of lower back pain with sharp pains shooting down both legs. The patient is evaluated and given an intramuscular (IM) injection of Toradol to treat the pain. The patient visit is assigned a level 3 facility E&M level and coded 96372 for the IM injection. No modifier 25 is appended to the E&M level because the status indicator is N (packaged service). The status indicator would need to be S, T, or Q1–Q3 to assign modifier 25.
The use of the modifiers 24 and 25 in E&M coding may seem confusing, but the guidelines above should help. When you clearly understand the global period for procedures, you will have a much easier time knowing when to assign modifier 24 and 25.
There are a lot of wrong modifier combinations like using modifier 50 or 59. We will be discussing those in our upcoming articles. Many of these invalid modifier combinations can be avoided if you have properly trained medical coding personnel. Another easy way is you can get connected with Medical Billers and Coders (MBC) who have such experts. These coders are constantly trained to stay on top of medical coding. To know more about our medical billing and coding services you can call us at 888-357-3226 or write to us at firstname.lastname@example.org