How to use Modifier 24 and 25

By Aimee Wilcox, MA, CST, CCS-P

Modifier 24 is reported as follows:

• Append only to Evaluation and Management (EM) codes.
• Use only to report an EM service beginning the day after a procedure performed by the same physician during the past 10 or 90 postoperative days.
• The patient’s record must document that the EM service was solely for the treatment of an underlying condition and not for postoperative care.

Example:

The patient is two weeks status post laryngectomy for cancer and is seen in the surgeon’s office for EM service to begin chemotherapy for the next six weeks. Documentation supports an established visit level 99214.

Code:  99214-24

Do not use Modifier 24 if the following circumstances apply:

• Surgical complication is considered part of the surgery package so would not qualify.
• Wound infection is part of the surgical package.
• Patient is admitted to skilled nursing facility for a condition related to the surgery.
• If the postoperative period (10 or 90 days) is over, the Modifier should not be used.
• Modifier 24 should not be used for services rendered on the same day as the procedure. (See Modifier 25 explained below).

How will the insurance company respond to Modifier 24?

Each insurance company has their own sets of rules for processing claims with Modifiers. Some of the responses you may experience include:

1. Denial of the claim as incidental to the service and leave it up to you to pursue appeal.
2. They may request proof that the service was unrelated to the minor or major surgery for which the postoperative period is applicable.
3. They can also pay the claim and then at a later date (sometimes up to three years) request proof that the service actually qualified for Modifier 24 and if not, request a refund of the monies paid.

Sometimes the patient scenario can be complicated, requiring the coder to think through each scenario to determine applicable services and Modifiers. Review the following scenario and see if you would have coded it correctly.

Example:

The patient is two weeks status post neuroplasty for carpal tunnel of the right hand and presents to his surgeon today for a new complaint of right knee swelling and pain. The patient has a history of fluid on the knee and following examination and x-ray, the physician decided it would be best to drain the fluid from the knee in the office. The procedure was performed, the patient put on antibiotics and scheduled him to return for follow-up exam in one week.

This is a case in which you would report multiple Modifiers. The patient is currently in a postoperative period due to a major procedure by the same physician. The EM service today is unrelated to the surgery and during this EM service, the decision is made to perform another procedure.

Coding:

1. Code the EM service and append Modifier 24 to explain that it is unrelated to the surgery with the 90 day postoperative period and then also append Modifier 25 to indicate that the decision to perform the procedure (draining fluid from the knee) was made during the EM service.
2. Code the knee procedure and append Modifier -79 to indicate that the procedure was performed during the 90-day postoperative period for the neuroplasty for carpal tunnel surgery.

Example: 99214-24, 25 and 27370-79

When to use Modifier 25

Modifier 25 indicates that on the day of a procedure, the patient’s condition required a significant and separately identifiable EM service above and beyond that which is usual for a pre- and post-operative care that is associated with the surgical procedure.

Example:

I saw my dermatologist for treatment of some dermatitis on my scalp that was itching and making me crazy. He wrote me a prescription for Prednisone and a special shampoo to help my scalp heal. He asked if there was anything else he could do for me and then I quickly remembered I had this suspicious spot on my neck that was not healing well and definitely wasn’t going away. I asked him to examine it, which he did, and recommended that I immediately have it biopsied. The biopsy was performed during the same office visit as my EM service.

Modifier 25 is used to report an evaluation and management service that is significantly unrelated to the surgical procedure performed on the same day. The two services I received were significantly different from each other and the procedure was not planned for the same day but rather occurred as a spontaneous decision made at the time of the physical examination.

Modifier 25 must be appended to an EM code and not a procedure or other service code.

What would happen if no Modifier was appended to the EM service?

Without Modifier 25 appended to the EM service, it would be denied as incidental to the surgical procedure performed the same day. In other words, the insurance company would believe that it was a preoperative service and deny it as included in the global package attached to the surgical procedure.

When the decision for surgery is made at the time of an EM service, but is performed as major surgery (not in the office), Modifier 25 is not applicable. Rather, Modifier 57 would be appended to the EM service to indicate this fact.

Coding Tip: Be sure to assign the proper diagnoses codes to match the service performed for each service. Do not put the diagnosis for which the major surgery was performed as this is not a visit related to that major surgery.

Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code.com.