1. Basics of Modifiers
Think of medical coding like ordering a customized meal at a restaurant. You have the main dish (the CPT® or HCPCS code), and the modifiers are like special instructions or side options you add to your order. For example, you might order a burger (CPT code) and specify "no pickles" or "extra cheese" (modifiers). These modifiers don't change what the burger is but clarify how you want it prepared.
Similarly, in medical coding:
Modifier: A two-character code added to a medical procedure code to give more details about the service provided.
Purpose: Clarifies specifics without changing the definition, like indicating a unique circumstance (e.g., an extra service or a repeated procedure).
Example: If a doctor performs an additional test on the same day, a modifier might be added to show that it's not a duplicate billing but an additional service.
2. Types of Modifiers
Modifiers are categorized into two main types:
Pricing Modifiers:
Impact Payment: These affect how much you'll get paid for the service. Think of these like specifying a more expensive ingredient in your meal.
Placement: Always go in the first modifier field.
Informational Modifiers:
Provide Extra Details: These don't change the payment but give more information about the service. It's like telling the chef you're allergic to peanuts but it doesn't change the price.
Placement: Used in the second, third, or fourth field if there's also a pricing modifier.
3. Modifier 24: Unrelated E/M During Global Period
Imagine you've ordered a meal (surgery) that comes with free refills for 90 days (postoperative period). If you order something completely different (unrelated Evaluation and Management (E/M) service), you need to indicate this so the restaurant (insurance) knows it's a separate request.
Modifier 24: Used for an unrelated E/M service during the postoperative period.
Rules:
Not used for services on the same day as the surgery.
Not used for complications of the original procedure.
Documentation must show that the E/M service was unrelated to postoperative care.
4. Modifier 25: E/M With Minor Procedure
Imagine you ordered a burger and also want a salad on the side. The salad (minor procedure) is separate but still part of your visit (E/M service). Modifier 25 indicates this separate service.
Modifier 25: Appended to E/M services with minor surgical procedures.
Conditions:
The E/M service must be significant and separately identifiable from the minor procedure.
Fees for basic E/M services are already included in the procedure's cost, so use this modifier cautiously.
Documentation must justify the additional E/M service.
5. Using Multiple Modifiers
Sometimes, more than one modifier is needed to fully describe the situation. Imagine you return to the restaurant within your free refill period (90-day global period) for a new type of meal (unrelated E/M service). If you then decide to add an extra dish (minor surgery), you need to clarify both aspects:
Example:
Modifier 24: Unrelated E/M during the postoperative period.
Modifier 25: Additional minor procedure on the same day as the E/M service.
Recap: How to Use Multiple Modifiers in Medical Coding
Key Points:
Modifiers provide extra details about medical services without changing their core definition.
Two Types: Pricing modifiers (affect payment) and informational modifiers (provide extra info).
Modifier 24: For unrelated E/M services during the postoperative period.
Modifier 25: For significant and separate E/M services with minor procedures.
Multiple Modifiers: Sometimes, you'll need to use more than one to accurately describe the services provided.
Examples
Example 1: Using Modifier 24
Scenario: Dr. Smith performed knee surgery on Patient A, which has a 90-day global period. Two weeks after the surgery, Patient A returns to Dr. Smith for an evaluation of a new issue: severe headaches unrelated to the knee surgery.
CPT Codes and Modifiers:
Knee Surgery Code: 29881 (Arthroscopy, knee, surgical)
E/M Service Code: 99213 (Office or other outpatient visit for the evaluation and management of an established patient)
Since the evaluation for the headaches is unrelated to the knee surgery and falls within the 90-day global period, Modifier 24 is used to indicate this.
Claim Submission:
99213-24 (Office visit for the evaluation of headaches during the postoperative period of knee surgery)
Example 2: Using Modifier 25
Scenario: Dr. Johnson sees Patient B for a regular check-up and, during the same visit, discovers a suspicious mole that needs to be removed. The removal of the mole is a minor procedure.
CPT Codes and Modifiers:
E/M Service Code: 99214 (Office or other outpatient visit for the evaluation and management of an established patient)
Minor Procedure Code: 11400 (Excision of benign lesion, trunk, arms, or legs; excised diameter 0.5 cm or less)
Because the mole removal is significant and separately identifiable from the regular check-up, Modifier 25 is used.
Claim Submission:
99214-25 (Office visit with a significant and separate evaluation and management service)
11400 (Removal of benign lesion)
Example 3: Using Multiple Modifiers (Modifiers 24 and 25)
Scenario: Dr. Brown performed a major abdominal surgery on Patient C, which has a 90-day global period. Four weeks later, Patient C returns for an evaluation of a new, unrelated complaint: shoulder pain. During this visit, Dr. Brown also decides to perform a minor procedure to drain a cyst on the shoulder.
CPT Codes and Modifiers:
Abdominal Surgery Code: 44120 (Enterectomy, resection of small intestine)
E/M Service Code: 99214 (Office or other outpatient visit for the evaluation and management of an established patient)
Minor Procedure Code: 10160 (Puncture aspiration of abscess, hematoma, bulla, or cyst)
Since the evaluation for the shoulder pain is unrelated to the abdominal surgery and falls within the 90-day global period, Modifier 24 is used. Additionally, because the cyst drainage is a separate and significant procedure from the E/M service, Modifier 25 is also applied.
Claim Submission:
99214-24 (Office visit for the evaluation of shoulder pain during the postoperative period of abdominal surgery)
10160-25 (Puncture aspiration of cyst as a significant and separate procedure from the E/M service)
Recap and Additional Points
Modifier 24:
Used for unrelated E/M services during a global period.
Example: A follow-up visit for a new issue like headaches or shoulder pain unrelated to the original surgery.
Modifier 25:
Used for significant, separately identifiable E/M services with minor procedures.
Example: A regular check-up where an additional minor procedure like mole removal is performed.
Multiple Modifiers:
Used when more than one modifier is needed to accurately describe the services.
Example: An unrelated E/M visit during the global period with an additional minor procedure.
Example: Using Modifiers 24 and 25 Simultaneously
Scenario: Dr. Taylor performed hip replacement surgery on Patient D, which has a 90-day global period. Six weeks after the surgery, Patient D visits Dr. Taylor for a follow-up due to new, unrelated symptoms of severe abdominal pain. During this visit, Dr. Taylor also finds a skin lesion that needs to be removed immediately.
Steps to Determine Modifiers:
Identify the E/M Service:
The visit for severe abdominal pain is unrelated to the hip replacement surgery.
This warrants the use of Modifier 24 to indicate the E/M service during the postoperative period.
Identify the Minor Procedure:
The removal of the skin lesion is a significant and separately identifiable service from the abdominal pain evaluation.
This warrants the use of Modifier 25 to indicate the additional procedure performed during the same visit.
CPT Codes and Modifiers:
Hip Replacement Surgery Code: 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip replacement])
E/M Service Code: 99214 (Office or other outpatient visit for the evaluation and management of an established patient)
Minor Procedure Code: 11401 (Excision of benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.6 to 1.0 cm)
Claim Submission:
E/M Service for Abdominal Pain:
Code: 99214
Modifier: 24 (to indicate the service is unrelated to the hip replacement surgery)
Complete Code: 99214-24
Minor Procedure for Skin Lesion Removal:
Code: 11401
Modifier: 25 (to indicate the procedure is significant and separately identifiable from the E/M service)
Complete Code: 11401-25
Final Claim Submission:
99214-24: Office visit for evaluation and management of severe abdominal pain during the postoperative period of hip replacement surgery.
Practice exam questions:] How to use multiple modifiers in medical coding! Certification exam tips!
Question 1
Scenario: Dr. Nguyen performed an appendectomy on Patient E, which has a 90-day global period. Four weeks later, Patient E visits Dr. Nguyen for an evaluation of chest pain, unrelated to the appendectomy. During the same visit, Dr. Nguyen also drains an abscess on the patient's arm.
Which set of modifiers should be used for this claim?
A. 99214, 10160-25
B. 99214-24, 10160-25
C. 99214-24, 10160
D. 99214, 10160
Answer: B. 99214-24, 10160-25
Rationale: Modifier 24 is used on the E/M service (99214) to indicate that the visit for chest pain is unrelated to the postoperative care of the appendectomy. Modifier 25 is used on the minor procedure (10160) to show that the abscess drainage is a significant, separately identifiable service performed during the same visit.
Question 2
Scenario: Dr. Kim performed a cholecystectomy on Patient F, which has a 90-day global period. Six weeks later, Patient F returns for an E/M visit due to abdominal pain related to the surgery. Dr. Kim also removes sutures during this visit.
Which modifier should be used for the E/M visit?
A. 24
B. 25
C. 57
D. No modifier needed
Answer: D. No modifier needed
Rationale: Since the abdominal pain is related to the cholecystectomy and falls within the global period, it is part of the global surgical package. Additionally, suture removal is considered part of the postoperative care. Therefore, no modifier is needed.
Question 3
Scenario: Dr. Patel performed cataract surgery on Patient G, which has a 90-day global period. Three weeks later, Patient G returns with an unrelated skin infection. During the same visit, Dr. Patel also performs a minor excision of a skin lesion.
Which set of modifiers should be used for this claim?
A. 99213-24, 11400-25
B. 99213, 11400
C. 99213-25, 11400-24
D. 99213-24, 11400
Answer: A. 99213-24, 11400-25
Rationale: Modifier 24 is used on the E/M service (99213) to indicate that the visit for the skin infection is unrelated to the cataract surgery. Modifier 25 is used on the minor procedure (11400) to indicate that the skin lesion excision is a significant, separately identifiable service from the E/M visit.
Question 4
Scenario: Dr. Lewis performed a hysterectomy on Patient H, which has a 90-day global period. Five weeks later, Patient H returns for an unrelated issue of back pain. During this visit, Dr. Lewis also performs a minor procedure of joint aspiration.
Which set of modifiers should be used for this claim?
A. 99214-24, 20610
B. 99214, 20610-24
C. 99214-24, 20610-25
D. 99214-25, 20610
Answer: C. 99214-24, 20610-25
Rationale: Modifier 24 is used on the E/M service (99214) to indicate that the visit for back pain is unrelated to the postoperative care of the hysterectomy. Modifier 25 is used on the minor procedure (20610) to show that the joint aspiration is a significant, separately identifiable service performed during the same visit.
Question 5
Scenario: Dr. Garcia performed a mastectomy on Patient I, which has a 90-day global period. Eight weeks later, Patient I returns for an evaluation of an unrelated upper respiratory infection. During the same visit, Dr. Garcia also performs a significant and separately identifiable minor procedure to excise a benign lesion on the patient's arm.
Which set of modifiers should be used for this claim?
A. 99213-24, 11401-25
B. 99213, 11401
C. 99213-24, 11401
D. 99213, 11401-25
Answer: A. 99213-24, 11401-25
Rationale: Modifier 24 is used on the E/M service (99213) to indicate that the visit for the upper respiratory infection is unrelated to the mastectomy. Modifier 25 is used on the minor procedure (11401) to indicate that the excision of the benign lesion is a significant, separately identifiable service from the E/M visit.
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How to use multiple modifiers in medical coding! Certification exam tips!
I hope this helps, please leave a comment on what you would like the next blog to be about. Txs, Jen