Modifier 25 and 59

Often it is very tempting for billing personnel to append a Modifier 25 or 59 to override or bypass the CCI edit process this is a common misuse of the 25 and 59 modifiers as this is not always the appropriate solution. It is important for billing personnel to understand that a modifier is used to modify a procedure or service but is not intended to change the definition of the CPT code.
Appending a Modifier 25 or 59 to bypass edits can be risky business potentially causing an audit for noncompliance. Because of this, it is imperative to understand both your federal and local guidelines when appending modifiers to claims based on your individual state and payer guidelines. With proper guidance and education in applying correct modifiers will allow your claims to make it through the edit process, allow for correct payment and ensure billing compliance. Keep in mind, payers consider modifier 59 the modifier of “Last Resort.”
Please refer to the CMS website to access Chapter 1 of the NCII Policy Manual and the Modifier 59 article.

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  1. Nigel says:

    Spot on with this write-up, I actually feel this site needs a lot more attention. I’ll probably be returning to read more, thanks for the advice!