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Modifier 25 Code Appendage and Usage
Modifier 25 Code Appendage and Usage
Append modifier 25 to E/M service when:
  • the E/M service is separate from the procedure performed, is not a part of the procedure, and is clearly documented in the medical record.
  • an initial hospital visit, initial inpatient consult and/or hospital discharge service is billed for the same date as inpatient dialysis providing the service is unrelated or cannot be rendered during the dialysis session.
  • preoperative critical care codes are billed within a global surgical period.
  • during a preventive care visit a significantly, separately identifiable acute care E/M service is also provided. In this instance, modifier 25 should be appended to the acute E/M service code, not the preventive service code.
  • during a routine foot care visit, a significantly, separately identifiable service is medically necessary.

 

The Health Plan recognizes the use of modifier 25 with E/M services within the following range:
CPT codes

  • 99201 - 99499 (E/M)
  • 92002 - 92014 (Ophthalmology)
  • 99026 - 99027(Hospital mandated on-call)
  • 98966-98969, 99441-99444 (Telephonic/On-line Evaluation)
  • 99050 - 99060 (Miscellaneous services)
HCPCS codes
  • G0101 (GYN cancer screening exam)
  • G0344 (Initial Preventive Physical Exam)
  • S0605 (Annual rectal exam)
  • S0610 - S0613 (Annual GYN exam)

 

Modifier 25 is not allowed:
  • On the day a procedure is performed if the patient's condition did not require an additional evaluation above and beyond the usual pre operative care required by the primary procedure.
  • On a surgical code, since this modifier explains the special circumstances of providing the E/M service on the same day as the procedure.
  • When reporting an E/M service that resulted in a decision to perform major surgery.
  • On days 2 through 10 when billing E/M services with minor procedures (Global Fee Period of 0-10.)
  • When billing E/M services for Pre-op service one day prior to a major procedure, and on day 2 through 90 of a major procedure (Global Fee Period of 90 days).
  • When billing:
    1. Anesthesia codes
    2. Surgery codes
    3. Radiology codes
    4. Lab / Path codes
    5. Medicine codes
    6. Category III codes
    7. HCPCS codes - All except G0101, G0344, S0605-S0613

 

Modifier 59 Code Appendage and Usage

Correct Use of Modifier 59
  • Use when billing a combination of codes that would normally not be billed together
  • This modifier indicates that the ordinarily bundled code represents a service done at a different anatomic site or different session on the same date
  • Use only on the procedure designated as the distinct procedural service
  • Ensure the medical record documentation is clear as to the separate, distinct procedure before appending modifier 59 to a code

 

Incorrect Use of Modifier 59
Modifier 59 is not allowed when:
  • a procedure/service was not independent or distinct from any other service performed on the same day, same session, same site or lesion.
  • there is another, existing modifier that better represents the service or procedure.
Modifier 59 is not used when billing:
  • E/M codes - 99201-99499
  • Codes considered as E/M - 92002-92014, 99026, 99027, 99050-99060, 98966-98969, 99441-99444, G0101, G0344 Codes S0605-S0613.
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