A Question Made To A Third-Party Payer Regarding A Claim Understanding Medical Claim Modifiers – The Modifier -25, -24, -51, -57, -59, -26

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Understanding Medical Claim Modifiers – The Modifier -25, -24, -51, -57, -59, -26

I am writing this article again as a suggestion from many of my readers on my blog. This article is more comprehensive in a way that scenarios were cited to have a bigger look on the proper use of some of these important modifiers.

In this article, I will be describing the medical claims modifiers – Modifier -25, -24, -51, -57, -59, -26.

Modifier -25, 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service:

This modifier must be appended with an E/M service. This is the modifier you will need to use with the evaluation and management service done on the same day with other procedure done by the same physician. It has to be above and beyond the usual preoperative and postoperative encounter with the procedure. In fact, by using this modifier, it doesn’t have to have a different diagnosis reported. The most important thing is that, the E/M level should meet its key components or if it is selected based on time with the patient (counseling and coordination). You have to be careful in using this modifier. It must meet medical necessity. As you know, there are procedures that already includes all other care and management.

Let’s describe this modifier 25:

A patient came in for her monthly follow up for her chronic back pain. At the same time, patient was complaining with severe headache. The pain doctor performed bilateral occipital block on the patient at the time of service. You will append modifier 25 for the E/M code to indicate that both services were rendered on the same day.

You don’t use modifier 25 with E/M encounter that resulted to Decision for Surgery (we have another modifier for this!)

Modifier -24, 24: Unrelated evaluation and management service by the same physician during postoperative period.

As the modifier indicates, this is another modifier that you can only append with an E/M counter. It indicates that the E/M encounter is not related during the global period.

Let’s describe this modifier 24:

A pain specialist performed facet nerve destruction for the patient. During the normal, postoperative global period, the patient came in to the office with severe knee pain due to fall on ice as evidenced by the patient’s subjective information. The pain specialist will then report that E/M encounter with the patient by appending modifier 24 to indicate that encounter is not related during the postoperative global period.

This modifier, like modifier 25 has no restriction as with the level of E/M code as long as it meets medical necessity, all its components or are time-based.

Modifier -57, 57: Decision for Surgery:

An Evaluation and Management service resulted in the initial decision to perform surgery during the E/M encounter.

Let’s describe this modifier:

An OB/GYN sees a patient who complains with severe abdominal pain. It turned out (through ultra sound, radiology and all other diagnostic testing and documentations), the patient is having an ectopic pregrancy. The OB/GYN performs the laparoscopic surgery on the same day. The E/M encounter will then be reported with modifier 57 which resulted to decision for surgery. The laparoscopic surgery should also be reported as performed on the same day without a modifier.

Modifier -50, 50: Bilateral Procedure

You will append modifier 50 for procedures that are obviously billable as bilateral (or two sides, both sides), performed on the same day, the same operative session, on identical anatomical sites, organs (arms, legs, spine).

A Facet Nerve block is unilateral (can be billed as bilateral). When using a modifier 50, make sure you only bill for one unit on the claim form since there is only 1 procedure is performed bilaterally. Though guidelines from other payers may differ. They may require you to list it twice (line 1 and line 2 on the claim form). You have to be responsible to clarify this with your payors.

You use this modifier with add-on codes too! Do not use this modifier with procedures which are already described as bilateral procedures.

Modifier -51, 51: Multiple Procedures

This modifier is used when reporting multiple procedures performed by the same physician on the same day. Do not use this modifier for “add-on” codes (see appendix D of the CPT Code book). Do not use this modifier for codes with “modifier -51 exempt” symbol (see appendix E of the CPT Code book). Do not use this modifier with an E/M code. This modifier can only be used by the same physician on the same day who performed the procedure.

Coding tip: List the highest reimbursable code (after the main procedure code) based on the fee schedule.

Modifier -59, 59: Distinct Procedural Service

Description of Modifier -59: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.

Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

Use this modifier only if the other procedure is a separately identifiable procedure code. Procedure that is distinct and can be described as independent procedure, on separate anatomical site, lesion, injury site, different organ system, and different session. Do not use this modifier for E/M code.

Modifier -26, 26: Professional Component

This modifier is used only for the professional component (physician) of a service or a procedure. Certain procedures are a combination of both professional and technical component. By using modifier 26, it indicates that procedure being reported as professional component only.

Professional Component versus the Technical Component. By illustration, procedures rendered at a facility such as outpatient hospital or ASC, these equipments are facility-owned. The facility will then report the technical component for such service while the physician will report the professional component for the that procedure. One very good example, the physician performs Paravertebral Facet Block under Fluoroscopic guidance using CPT code 77003. The physician will report the fluoro with modifier 26 for his/her professional component. While the facility will report the same procedure with modifier -TC for the technical component.

Modifier -LT or -RT are used to indicate a Left or Right side or anatomical site. So if the pain specialist performed Left Cervical Facet Block, you will append a modifier -LT to report this procedure.The above modifiers are used to describe your claims for the services performed on the patient for appropriate payment. Always consult your local careers and third party payors for local determination, policies and guidelines on these modifiers. Looking at the edits is also very important!

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