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Appropriate Usage Claims Modifiers

The document outlines the appropriate use of modifiers 25 and 59 in billing practices, specifically for Evaluation and Management (E&M) services and other procedures. Modifier 25 is used for significant, separately identifiable E&M services on the same day as a procedure, while modifier 59 identifies distinct procedural services that are not typically reported together. Providers are advised to consult the National Correct Coding Initiative Policy Manual for detailed guidance on modifier usage.

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7 views2 pages

Appropriate Usage Claims Modifiers

The document outlines the appropriate use of modifiers 25 and 59 in billing practices, specifically for Evaluation and Management (E&M) services and other procedures. Modifier 25 is used for significant, separately identifiable E&M services on the same day as a procedure, while modifier 59 identifies distinct procedural services that are not typically reported together. Providers are advised to consult the National Correct Coding Initiative Policy Manual for detailed guidance on modifier usage.

Uploaded by

revathy
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© © All Rights Reserved
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Supplemental Billing Information: Appropriate Use of Modifiers 25 and 59

The Current Procedural Terminology (CPT) defines modifier 25 as a “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.”

General Guidelines for Modifier 25 from the CPT:

 Modifier 25 may be appended only to Evaluation and Management (E&M) codes


within the range of 92002 – 92014 and 99201 – 99499.
 To appropriately append modifier 25 to an E&M code, the provided service must
meet the definition of “significant, separately identifiable E&M service” as
defined by CPT.
 When appending modifier 25 to an E&M service billed on the same date of
service as a procedure or other service, documentation for the additional E&M
must be entered in a separate section of the medical record in order to validate
the separate and distinct nature of the E&M service. The additional E&M service
must be able to stand alone as a billable service with no overlapping of key E&M
components (e.g., medical history, medical examination, and medical decision-
making performed).

The CPT defines modifier 59 as a “distinct procedural service.”

General Guidelines for Modifier 59 from the CPT:

 Modifier 59 is used to identify procedures/services, other than E&M services,


that are not normally reported together, but are appropriate under the
circumstances.
o Modifier 59 should not be appended to an E&M code. To report a separate
and distinct E&M service with a non-E&M service performed on the same
date, see modifier 25.
 When appending modifier 59, documentation must support that the
procedure/service represents a different session or patient encounter,
procedure or surgery, anatomic site or organ system, lesion (through a separate
performed incision/excision or for a separate injury or area of extensive
injuries), or procedure not typically performed on the same day by the same
individual.
 Modifier 59 should only be reported if a more descriptive modifier (e.g.,
modifier XE, XP, XS, or XU) is unavailable, and it is the most accurate modifier
that is available to describe the circumstances.

Important Note: This information is for educational purposes only. It is ultimately


up to the provider to determine what to bill based on the services furnished.

It is recommended that providers and other interested parties refer to the National Correct
Coding Initiative (NCCI) Policy Manual for Medicaid Services (NCCI Policy Manual) and the
Modifier 59 article (Modifier 59 Article) for detailed information regarding appropriate modifier
usage, which can be found on the CMS Medicaid.gov website.

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