3 Medical Coding Modifiers You Probably Need to Brush Up On

When used appropriately, coding modifiers help practices code appropriately and collect revenue to which they’re entitled. The key here is "when used appropriately."

“You still have to review the documentation to make sure it supports the requirements for adding the modifier,” says Angie Clements, CPC, CPC-I, CEMC, CGSC, COSC, CCS, physician coding auditor at MedKoder, LLC. Just because a modifier could technically apply, doesn’t mean that one is warranted, she adds. 

(See Medical Billing Best Practices Checklist for more areas to brush up on.) 

In this article, Clements addresses three of the most problematic modifiers in physician practices and provides tips for compliance.

Modifier -59: Distinct or Not Distinct?

Modifier -59 identifies a procedure or service that’s distinct or independent from another non-evaluation and management (E/M) service performed on the same day. When coders append modifier -59, they essentially bypass Medicare’s National Correct Coding Initiative (NCCI) procedure-to-procedure edits and prompt payers to pay separately for both procedures or services, Clements explains.

She provides these four tips to ensure compliance:

1. 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.

2. 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. Clements provides this example: A podiatrist debrides a toe nail and debrides a lesion on the same toe. In this scenario, coders cannot report both procedures together using modifier -59 because they’re performed on the same site. Instead, report the lesion debridement only. If, however, the physician debrides all 10 toes but only removes a lesion on one toe, the coder can bill both the lesion removal and debridement together using a modifier -59 appended to the code for the nail debridement.

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

4. Think of modifier -59 as a ‘last resort.’ Only append it when no other modifier (e.g., -RT or -LT) is more appropriate. Clements provides this example: A patient fractures his right and left tibia. A physician treats both with a closed reduction without manipulation. In this case, report the closed reduction code twice using -RT and -LT modifiers rather than modifier -59. Some payers may require a modifier -50 instead of -RT or -LT, says Clements.

Modifier -25: Same Physician, Same Day E/M Services

Modifier -25 denotes a significant and separately identifiable E/M service provided by the same physician to the same patient on the same day as another procedure or service within a global fee period. This modifier is all about the E/M service. When coders append modifier -25, they bypass NCCI edits and prompt payers to pay separately for the E/M service even though a global period exists, says Clements.

She provides these three tips to ensure compliance:

1. 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.

2. 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.

“A physician can do the work, but if they don’t document it, they shouldn’t bill it,” says Clements.

She provides this example: A patient presents to the orthopedist for treatment of osteoarthritis in the knee. The physician decides to provide the first in a series of three Synvisc injections administered over a three-week period. The patient returns during week #2 for injection #2, but the physician doesn’t address any other problems. In this case, coders should only report the injection when the patient presents for the second visit—not an additional E/M code with modifier -25. If, on the other hand, the physician performs a separate assessment for arthritis in the hand, the E/M may be separately reportable with modifier -25 assuming documentation supports the code assignment, says Clements.

3. 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.

Clements provides these four tips to ensure compliance:

1. 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, says Clements.

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.

2. 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, says Clements.

3. Know what constitutes ‘same physician.’ This modifier applies to the same specialty group—not necessarily the same individual physician, says Clements.

4. 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.