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Procedure Code Modifiers
Common Procedure Code Modifiers
Common Procedure Code Modifiers

Modifier 25 Use

Correct Use of Modifier 25 for E/M Services:

  1. 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.
  2. 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.
  3. Preoperative critical care codes are billed within a global surgical period.
  4. 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.
  5. During a routine foot care visit, a significantly, separately identifiable service is medically necessary.

We recognize the use of Modifier 25 for these code ranges:

  • 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:

  1. 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.
  2. On a surgical code, since this modifier explains the special circumstances of providing the E/M service on the same day as the procedure.
  3. When reporting an E/M service that resulted in a decision to perform major surgery.
  4. On days 2 through 10 when billing E/M services with minor procedures (Global Fee Period of 0 - 10).
  5. 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).
  6. When billing:
    • Anesthesia
    • Surgery
    • Radiology
    • Lab / Path
    • Medicine
    • Category III codes
    • HCPCS Codes: All except G0101, G0344, S0605 - S0613

Modifier 59 Use

Correct Use of Modifier 59:

  1. When billing a combination of codes that would normally not be billed together.
  2. To indicate that the ordinarily bundled code represents a service done at a different anatomic site or different session on the same date.
  3. Use only on the procedure designated as the distinct procedural service.
  4. Ensure the medical record documentation is clear as to the separate, distinct procedure before appending modifier 59 to a code.

Modifier 59 is not allowed when:

  1. A procedure/service was not independent or distinct from any other service performed on the same day, same session, same site or lesion.
  2. There is another, existing modifier that better represents the service or procedure.
  3. 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.

Modifier 33 Use - Preventive Services

Health Care Reform legislation under the Protection and Affordable Care Act (PPACA) outlines mandated preventive services and codes for which modifier 33 is required. Any copayments, coinsurances or deductibles called for under the member’s benefit plan are not applicable for these services.

If the preventive care is provided during an office visit please be aware that a copayment for the visit may apply if:

  • The preventive care is not the primary purpose of the office visit
  • The preventive service is billed with other services that require copayment.

It is important to verify benefits and eligibility when delivering any of the preventive services included in the mandate. Please verify benefits and eligibility prior to rendering services.

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