Know the Right Time to Append E/M Modifiers
Understanding the appropriate use of modifiers 24, 25, and 57 ensures proper payment.
Modifiers 24, 25, and 57 are often misunderstood. Each modifier has specific circumstances for use. Proper application of these modifiers will yield higher reimbursements for your providers, regardless of the clinical scope of your practice.
The 2018 CPT® code book defines these modifiers as:
|24||Unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period|
|25||Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service|
|57||Decision for surgery|
These specific modifiers are appended to evaluation and management (E/M) codes, only. Use them in accordance to global surgery guidelines, set forth by the Centers for Medicare & Medicaid Services (CMS) in the National Correct Coding Initiative (NCCI) edits.
Consider the Global Period
When an E/M service is billed in the global period of a procedure without a modifier, the E/M service is denied as incidental to the procedure. Chapter 1 of the NCCI Policy Manual for Medicare Services (CMS, revision date Jan. 1, 2018) defines when it is appropriate to bill a separate E/M service and use these modifiers to secure separate reimbursement. The Medicare Learning Network (MLN) released a general information booklet entitled the Global Surgery Booklet (CMS 2017), which defines services considered part of the global treatment for a procedure.
CMS advises there is an E/M component of every procedure in the CPT® code book. CMS also designated every procedure with a 0-, 10-, or 90-day global period. Necessary components of every procedure include:
- The decision to perform a procedure,
- Ensuring the patient is healthy enough to receive the procedure, and
- Informing the patient about the procedure.
E/M services within these global periods that meet these criteria are not separately payable and should not be reported; however, when providers render E/M services within these global periods that do not meet the above criteria, append the appropriate modifier to ensure separate reimbursement.
Modifier 24 is used if the E/M service is within the 10- or 90-day global period but is unrelated to the procedure. It is not used for an E/M service on the same day as a procedure. For example: A patient has a fractured wrist. The patient comes into the office during the 90-day global period of the fractured wrist to discuss knee pain. The knee pain is completely unrelated to the wrist fracture treatment, so the provider should get separate reimbursement for the E/M service rendered that day. To communicate this to the payer, append modifier 24 to the appropriate E/M code.
Unexpected complications of a procedure can also result in an E/M service that goes above the routine care included in the global period of a procedure. If a new history, exam, and medical decision-making (MDM) are rendered, you may bill an E/M service with modifier 24 appended, even if those services are provided to the same body part that is already in a global period.
Modifier 25 is used if the E/M service is rendered the same day as a procedure with a 0- or 10-day global period. The debate over appropriate use of modifier 25 has been ongoing for years. The Office of Inspector General (OIG) routinely finds this modifier misused
The decision to perform a procedure cannot be the sole justification for coding a separate E/M with modifier 25. Similarly, being a new patient is not justification alone for billing a separate E/M (CMS, NCCI Policy Manual for Medicare Services, revision date Jan. 1).
If an E/M service is unrelated to the procedure, or if the E/M service goes above and beyond the decision-making required for the procedure, the provider should get separate reimbursement for that work, and modifier 25 should be appended to the E/M code.
Modifier 57 is used when an E/M service is rendered within the three days preceding, or on the same day as, a procedure with a 90-day global period. This is common when urgent surgical treatment is required. In this case, the decision to proceed with treatment is an integral component of the E/M service. If the decision to proceed with surgery is made greater than three days prior to the procedure, modifier 57 is not required on the E/M code.
The use of modifiers 24, 25, and 57 are dependent on:
- The global period of the procedure
- The timing of the E/M service in relation to the procedure
- The relation of the E/M service to the procedure
E/M services billed with any of these three modifiers are commonly audited. Be sure documentation supports the use of these modifiers to protect yourself and your provider in the event of an audit. Using these modifiers appropriately will reduce denials and ensure your practitioners get paid for additional work provided in global periods.
Elizabeth Redman, CPC, COSC, is the billing department manager for Buffalo Orthopaedic Group, LLP. She has 20 years’ experience in healthcare administration and in various specialties and has worked in New York and Nevada. Redman’s focus is on orthopedic coding and insurance accounts receivables. She is a member of the Buffalo, N.Y., local chapter.
CMS, Global Surgery Booklet (August 2017): www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf
CMS, NCCI Policy Manual for Medicare Services, chapter 1, page 18, (revision date Jan. 1):
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