Modifier 25 vs 59: Avoiding Confusion
Modifier 25 vs 59: There has been much confusion over the difference between and use of modifiers 25 and 59. In 2008, the description of modifier 59 was edited in the CPT manual to clarify the distinction between two. When applied to CPT codes, both modifiers indicate: two services billed on the same date of service but not typically billed together, were separate and distinct from one another. It is important to understand the use of these modifiers since they probably are the top two modifiers in your practice when billed for multiple services on the same date. The modifiers are described as follows:
As described by CPT: Modifier 25 is used to denote a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.” Modifier 25 should only be submitted on an E/M code. The medical records should reflect the significant, separately identifiable service. Physicians and providers should consult the CPT Manual for details regarding code combinations in addition to CMS NCCI edits.
As described by CPT: “Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together that may be appropriate under certain circumstances. Documentation must support a different session, 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 individual.”
General Guidelines for Modifier 25
- Modifier 25 may be appended only to Evaluation and Management (E&M) codes within the range of 92002 – 92014 and 99201 – 99499.
- To appropriately append modifier 25 to an E&M code, the provided service must meet the definition of “significant, separately identifiable E&M service” as defined by CPT.
- When appending modifier 25 to an E&M service billed on the same date of service as a procedure or other service, documentation for the additional E&M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E&M service. The additional E&M service must be able to stand alone as a billable service with no overlapping of key E&M components (e.g., medical history, medical examination, and medical decision-making performed).
General Guidelines for Modifier 59
- Modifier 59 is used to identify procedures/services, other than E&M services, that are not normally reported together but are appropriate under the circumstances.
- Modifier 59 should not be appended to an E&M code. To report a separate and distinct E&M service with a non-E&M service performed on the same date, see modifier 25.
- When appending modifier 59, documentation must support that the procedure/service represents a different session or patient encounter, procedure or surgery, anatomic site or organ system, lesion (through a separate performed incision/excision or for a separate injury or area of extensive injuries), or procedure not typically performed on the same day by the same individual.
- Modifier 59 should only be reported if a more descriptive modifier (e.g., modifier XE, XP, XS, or XU) is unavailable, and it is the most accurate modifier that is available to describe the circumstances.
When Not to Use the Modifier 25
- Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery.
- Do not add modifier 25 if there is only an E/M service performed during the office visit and no procedure.
- Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable.
When to Use the Modifier 59
59 should only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes. If there is another modifier that more accurately describes the services being billed, it should be used in place of the 59 modifier. Your documentation should support that you performed those services separately and distinctly of one another.
Examples of Modifier 25
A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit, it is determined the patient needs a cardiovascular stress test that same day. The physician codes an E/M visit (99214) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure.
A second example would be if the physician performs an initial or subsequent Medicare Annual Wellness Visit (coded as HCPCS codes G0438 or G0439) to establish or maintain the patient’s personalized prevention plan, and also provides an E/M service (CPT codes 99201-99215) for a medical condition on the same date of service. Then, the physician must add modifier 25 to the medically necessary E/M service, to be reimbursed for both services. The same coding logic applies when an Initial Preventive Physical Examination (IPPE) is provided on the same date as a medically necessary E/M service.
Examples of Modifier 59
A dermatologist does a Photo Dynamic Therapy session with a BLU-U machine on the face/scalp of a patient. Following the face/scalp session, the BLU-U was repositioned to treat other extremities. The first code is the face/scalp performed on the patient. Then, modifier 59 is added to the second procedure indicating a distinctly different procedure performed on separate extremities.
There are relatively few NCCI edits that involve E/M services, but here are two examples:
- If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with psychological testing (such as CPT code 96101), modifier 59 would be appended to the testing code.
- If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with a demonstration of home monitoring of a patient’s international normalized ratio (e.g., HCPCS code G0248), modifier 59 would be appended to the demonstration code.
Whether it’s modifier 25 vs 59 or any other modifiers, the overall effect of modifiers is to alert the payer to acceptable deviations from the CPT coding rules. The modifiers will not be used on all claims; the popular wisdom is that modifier use will be the exception rather than the rule. But there will be times when a modifier is needed. In all cases, physicians should remember that the documentation must show that the two services were separate and distinct.
Modifiers © Copyright 2021 American Medical Association
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