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Gastroenterology Coding Alert


Check These 7 Facts About Common E/M Modifiers

Yes, you can use both modifier 24 and 25 together sometimes, Part B reps note.

GI practices typically report E/M services every day, but sometimes those claims aren’t as straightforward as simply billing the right code and collecting payment. In some cases, you’ll have to append modifiers to your E/M codes to ensure you get paid appropriately, and in those situations, you may have to navigate delicate regulations that guide how to use them.

Part B representatives aimed to clear up such confusion during the April 23 webinar “Evaluation and Management Modifiers,” presented by Part B payer NGS Medicare. We’ve rounded up a few of the guidelines most applicable to gastroenterology practices, and we’re sharing them below to ensure that you bill these appropriately.

1. Know What the Modifiers Do

“A modifier is a two-position alpha or numeric code added to the end of a CPT® or HCPCS code to clarify the service being billed,” said NGS’ Michele Poulos during the call. “A modifier provides the physician with the means to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition of the code.” Modifiers also help eliminate the appearance of duplication or unbundling, she added.

Keep in mind: The documentation must support the use of the modifier, and not all modifiers are recognized by Medicare.

2. Remember the 2 Types of Modifiers

The modifiers fall into two main categories, Poulos notes. Pricing modifiers impact the payment amounts you’ll receive and should always be placed in the first modifier field. Informational modifiers, however, provide additional information regarding the service being performed, but do not affect the payment amount, and should be used in the second, third, or fourth field if a pricing modifier is also being used.

“The multicarrier systems used for claims processing allows up to four modifiers per claim line,” she added.

3. Use Modifier 24 for Unrelated E/Ms During Global

You’ll use modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) “when an unrelated E/M service or eye exam is performed by the same physician during the postoperative period of a procedure with a 10- or 90-day global period,” Poulos said.

You should never use modifier 24 for services rendered on the same day as the surgical procedure — in those cases, you’ll typically use modifier 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) instead, Poulos said. In addition, you’ll never use modifier 24 for a complication of the original procedure, you can’t append it to the surgical procedure code, and it doesn’t apply to the removal of sutures or other wound treatment, since these are part of the surgical service. “These are all common denial reasons for this modifier,” she noted.

Documentation must support the fact that the E/M visit was unrelated to the postoperative care, and the diagnosis should clearly indicate the reason for the unrelated postoperative encounter, Poulos added.

4. Modifier 25 Applies to E/M With Minor Procedure

“Modifier 25 may be appended to E/M services that are reported with minor surgical procedures with global periods of 0 or 10 days, or procedures not covered by global surgery rules,” Poulos said. Remember that the E/M service performed with the procedure must be both significant and separately identifiable to justify the use of modifier 25. Minor surgeries and procedures include pre-procedure, intra-procedure, and post-procedure work, so you should never report a separate E/M service for this work, she said.

“Remember that the fees for E/M services are already built into the surgical procedure, so you should be very cautious when you decide to use this modifier, and your physician should make that decision that in their profes­sional opinion, the E/M service they’re providing is above and beyond the E/M service already associated with the procedure.”

Remember these best practices: If the patient sees one specialist for an E/M and another specialist for a procedure, then modifier 25 isn’t necessary, because the providers aren’t the same specialty, Poulos said. Documen­tation must support the procedure as a separate and distinct service, and an appropriate ICD-10 code should be appended. “These services do not require a different diagnosis to be reported on the claim,” Poulos noted. “If you do have two separate diagnosis codes, you want to report them and use the diagnosis pointer on the claim to indicate which diagnosis code applies to which service, but it is acceptable to use just one diagnosis code.”

5. Sometimes You’ll Use Multiple Modifiers

In some situations, one modifier may not be sufficient, Poulos noted. For instance, if a patient has a major surgery with a 90-day global period and returns to the provider within those 90 days for an unrelated E/M, this would require modifier 24. However, if, during that E/M service, the physician determines it’s necessary to perform a minor surgery or procedure unrelated to the prior one, you’ll be using two modifiers.

“If this minor surgery or procedure is significant and separately identifiable from the E/M and unrelated to the original major surgery, you would report both modifiers 24 and 25,” Poulos said. “So just to clarify, the 24 modifier would be used because the E/M service is unrelated and performed during the postoperative period of that major surgery. Modifier 25 would be necessary to identify that the minor surgery or procedure performed on the same day is separately identifiable.”

6. Use Modifier 57 for Decision to Perform Surgery

“An E/M service that results in the initial decision to perform a surgery may be identified by adding modifier 57 (Decision for surgery) to the appropriate level of E/M service,” Poulos said. This should be used for E/M services on the day of or on the day before a procedure with a 90-day global period, if the decision to perform the major surgery happens then.

“Certain situations may require the use of both modifiers 24 and 57,” she said. “This can occur when a provider is billing an E/M service resulting in the initial decision to perform a major surgery during the postoperative period of another procedure.”

Example: On Feb. 2, the physician performs an incision and drainage of an abscess (11400, Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less). This code has a 10-day aftercare period. On Feb. 8, 2020, the patient returns with sharp abdominal pain, and after an E/M, the decision is made to perform an appendectomy. On Feb. 8, you’ll report 99214-24-57 along with 44970 (Laparoscopy, surgical, appendectomy). The two modifiers show the payer that the procedure is unrelated to the I&D and, also, the decision for surgery is made on the same date as the appendectomy.

7. Mind the NCCI Edits

When appropriately billing these modifiers, keep an eye on the National Correct Coding Initiative (NCCI) edits, said NGS’ Arlene Dunphy, CPC, during the call. “The NCCI procedure-to-procedure code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B covered services,” she said. These edits apply to all fee-for-service Medicare beneficiaries.

All line items for the same national provider identifier (NPI), date of service, and beneficiary are subject to the NCCI edits, so if a provider submits two codes from a pair together for the same beneficiary on the same date of service, the column 1 code is eligible for payment and the column 2 code is denied, Dunphy said.

However, if both services are clinically appropriate and an appropriate modifier is used on the column 2 code, then the service may be eligible for payment, Dunphy added. “But we would expect to see some supporting documentation in the beneficiary’s medical record to support the unbundling of those services. That could be a different session, different procedure or surgery – the information like that is going to support you unbundling those services.”