E/M Modifiers: Defining Your Problem

A clear understanding of E/M modifiers ensures an accurate portrayal of services.

By Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS

One can read the definitions for the words modifier and modify and have a pretty clear understanding as to what these two words mean. A better question is what do they mean for the health care community? If we apply the definitions above to our evaluation and management (E/M) services, the meanings of these two words become uncertain.

To make an E/M service “less extreme” or to “limit or restrict the meaning of” it doesn’t adequately represent what we are trying to do when we submit an E/M service to an insurance company. We usually tell them something more extreme or we want to illustrate a major change, not a minor change.

Evaluation and Management – CEMC

A Defining Moment

Modifiers 25 and 57, by definition, look very much alike. However, they tell two different stories to the payers.

Modifier 25 is appended to any E/M service when a “separately identifiable” evaluation and management service is provided by the same physician on the same day as a procedure. Exactly what does that mean? The Office of Inspector General (OIG) identifies the meaning of this modifier to be one that needs further investigation. The provider community doesn’t always understand the definition of this modifier and its use.

Consider the following scenario and the use of modifier 25:

A new patient is sent to a specialist’s office at the request of his PCP for the removal of several skin tags on his back. The patient is seen by the specialist and provides a brief history of the skin tags and the desire for their removal. They bother him when he’s dressing, they sometimes bleed, and they can become irritated by certain fabrics he wears. The examination is limited to the patient’s back and the skin tags. The specialist then prepares the patient for the procedure and removes the cyst. The specialist then bills a 99203-25 and 11200. The insurance company asks to see the notes for these services.

Was this billed correctly? Should the visit and the procedure have been billed?

The quick and easy answer is that the E/M service must be separately identifiable. The diagnosis may not be different than the one submitted for the procedure, but it should be clear from the documentation that the visit can stand on its own. Each procedure has within its reimbursement structure a brief visit. The visit illustrated above appears to represent only the  visit inherent to the procedure  and not a separately identifiable visit. The only service that should be billed by the specialist’s office is the 11200.

Modifier 57 is used when a patient is seen prior to a surgery (with a 90 day global period) within one calendar day. An example of this is when a patient is seen in the Emergency Room and, during the extensive consultation, it’s determined that the patient needs surgery within the next calendar day. Both the surgery determination visit and the surgery itself could be reimbursable if modifier 57 is applied to the E/M service.

Consider the following example and use of modifier 57:

A general surgeon is consulted to the ER for abdominal pain. The patient is interviewed in depth, a complete exam is done, labs and CT scans are reviewed, and a discussion occurs between the ER physician and the general surgeon. During this visit, the general surgeon determines the patient will need to undergo a laporscopic cholecystectomy. All of this is well documented by the general surgeon. The surgeon bills for the consultation (99254) with modifier 57 appended. The cholecystectomy is billed (47562).

Looking at that same patient, with the laporscopic cholecystectomy is being seen post operative day three (3) for possible discharge by the general surgeon.

She is expressing continued pain in her abdomen that she believes is not at all related to the surgical wound. A thorough examination of the patient and continued questioning leads the surgeon to think the patient may also have appendicitis. He orders a follow-up CT scan and additional lab tests to further diagnose this new problem.

A welcome sight for this situation is modifier 24. This visit turned out to be unrelated to the surgery and the discharge wasn’t planned at this point. There is new pain. There is a new diagnosis. The surgeon, in taking care of this new problem, should clearly illustrate within the body of his note that this is a new problem and unrelated to the surgery that took place three days ago. Once the documentation clearly states this, modifier 24 can be appended to the subsequent hospital visit code (99231-99233).

Modifier 24 could not be added if the pain was related to the surgical incision, or at all involved in routine post-operative situations. Medicare goes further in stating that any post-operative complication related to the surgery isn’t billable unless it’s a return to the Operative Suite (78 modifiers, not discussed here). Checking with your top payers may glean additional information about this requirement — as some payers will not allow for routine post-operative care, but will allow more extensive issues submitted for consideration.

In conclusion, 24, 25, and 57 are certainly the most helpful E/M modifiers. But, in the same vein, they are also the three misunderstood modifiers. With a vivid picture of when you should use these modifiers, it is logical as to how they can benefit the physicians while accurately portraying services to insurance companies.

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