Modifier - 24, 25 & 57, are
used only with E&M codes under various circumstances are described below
with some common example,
Modifier 24 - Unrelated Evaluation and Management by the same physician
during a postoperative period.
When
an unrelated E/M service is performed by the same physician during the
postoperative (global period -10 or 90-day postoperative period) then append
modifier 24 to the E/M procedure code.
Eg:
A surgeon performs Puncture aspiration of abscess - CPT 10160 on 1st Jan 2014
which is 10 days of global period surgery.
And
the same patient returns on 5th Jan 2014 for some other reason apart from the
previously performed surgery eg: abdominal pain, Then we should report this
E&M service with modifier 24.
Note: Make sure that we
are not assigning the same diagnosis code which is the reason for the surgery
which was performed earlier, and then there would be a chance of claim get
denied.
Eg: DOS: 1st
Jan 2015
First
Procedure:
10160 Dx.
Abscess in leg
Eg: DOS: 5th Jan 2015
Within
the global period for another reason: 99214 - 24 Dx. Abdominal pain
Exception - When
the patient returns on 5th Jan 2014 for the same reason related to previous
surgery for a checkup or follow up then we should assign CPT 99024
(Postoperative follow-up visit) instead of adding modifier 24.
Eg: DOS: 1st Jan 2015
First Procedure: 10160 Dx. Abscess in leg
Eg: DOS 5th Jan 2015
Within the global period for the same reason: 99024 Dx. Abscess in leg
Modifier 25 - Significant, Separately Identifiable
Evaluation and Management Service by the same physician on the same day
When a minor surgery (0
days or 10 days global period) was performed on the same day along with E&M
service then append modifier 25 to the E&M procedure code.
Eg: A surgeon
performs 10160 and E&M on 10th Feb 2015, Report E&M with modifier 25.
DOS: 10th Feb 2015
Procedure: 99214
- 25
10160
When 2 E&M services
were performed on the same day, under this circumstance, we can assign
modifier 25 with the first listed E&M
Eg:
E&M and Preventive visit were performed on the same day 5th Feb 2015,
Report first E&M service with 25 modifier
DOS: 5th Feb 2015
Procedure: 99213
- 25
99393
Note: When the E&M
is performed with Radiology and pathology section on the same day then we
should not append modifier 25 with E&M.
We should append
modifier 25 with E&M when surgery codes or some of the medicine section
codes being assigned on the same day with E&M service.
Eg:
E&M and vaccine codes were performed on the same day, Then report E&M
with modifier 25
DOS: 1st April 2015
Procedure: 99212
- 25
90471
90715
Modifier 57 - Decision for surgery.
When
a major surgery (90 days global period) performed with E&M on the same day or a day before, (In both these cases, the E/M service is provided by the same
physician, either the day before or the day of major surgery) Append modifier
57 to the E&M procedure code.
E.g.
A surgeon performs E&M and 21820 (Closed treatment of sternum fracture) on
1st Mar 2014 which is 90 days global period, Append modifier 57 to the E&M.
Eg: DOS: 1st Mar 2014
Procedure:
99215 - 57
21820
Global periods:
10 days: Day
of surgery - Next day/Postoperative day 1 to 10 days immediately following the
date of surgery
90
days: One day before the day of surgery - Day of surgery
- Next-day / postoperative day 1 to 90 days immediately following the date of
surgery.
CPT 99024:
When to use CPT 99024
Instead of Modifier 24?
When the patient returns
back to visit the same physician who has performed 10 days or 90 days of global
surgery for the patient and the reason for the visit is related to the surgery,
We should use CPT 99024 (Postoperative follow-up visit, normally included in
the surgical package, to indicate that an evaluation and management service was
performed during a postoperative period for a reason(s) related to the original
procedure)
When we can append both
24 and 25 modifiers with the E&M?
When the E&M falls
within the 10 days or 90 global periods and there are 10 days global surgery is
performed on the same day. Then we should use both the modifier (24 and 25)
with the E&M.
Eg: DOS:
1st Jan 2015
Procedure:
99214 - 57
21820
21820 is 90 days global
procedure hence we appended modifier 57 with the E&M since it is 90 days
global whatever the procedure has been performed within the next 90 days from
the date of surgery (1st Jan 2015) then we have to check whether it’s for the
same reason then we should use CPT 99024 and if it’s for the different reason not
for a checkup or follow up then we should append modifier 24 with the office
visit.
DOS:
1st Feb 2015
Procedure:
99213 - 24, 25
10160
In the above scenario,
The E&M falls within the Global period hence we appended modifier 24 and
there is a same day minor surgery hence appended modifier 25 also.
We
have to understand the basic concepts of modifier 24, 25 and 57 and when to use
and where to use which modifier to use is very important for the coders to avoid
unnecessary denials. We have to go back and check the patient history for any
previous 10 days or 90 days global procedures were performed or not to append
modifier 24.
Some other modifiers
which we are using during global periods are Modifier 78, 79 and 58 are with
the surgery codes not with the E&M codes.