by Diane E. Zucker, M.Ed., CCS-P
Health Care Management Consultant
The concept of modifiers and CPT coding is fairly straightforward, however sometimes we add modifiers without thinking about long term consequences and the view from the insurance side of payment. Here are a few basic facts to consider as you append a modifier:
The RT, LT or modifier 50 are never appended to an E/M code. They may be appended to diagnostic codes (imaging).
The E/M modifiers support the payment of the E/M service with a surgical or diagnostic service as a separate payment and do not impact the payment of the surgical care.
Remember for traditional Medicare the patient is responsible for 20% of the approved charges. For Advantage Plans it may be a set dollar amount for the services provided and for commercial insurance plans it may be a mix of first dollar coverage, amounts applied to a deductible or a set percentage of the approved amount.
First, this modifier is not required on initial or new patient visits using either the Ophthalmology coding process or the E/M codes.
Modifier 25 may be required when the same provider is also performing specific diagnostic testing on the same day as an E/M or vision service, however not all insurance programs required modifier 25 in these cases.
The definition of Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service.
The coding of an E/M on the same day would indicate the documentation supported the E/M service beyond the usual procedure pre and post care and that the assessment for the procedure was significant and documented to support either additional medical or surgical issues impacting the patient care (diabetes, glaucoma, deafness in a vision patient).
If the procedure is scheduled as part of a prior visit or assessment, then normally the service would be coded as the procedure alone.
The use of modifier -25 is normally used for minor procedures that either have zero (0) or ten (10) days as part of their pre, intra and post procedure care process.
The definition of modifier 24 an unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period. Medicare defines same physician as physicians in the same group practice who are of the same specialty.
Modifier -24 cannot be used when one assessed, diagnoses and planned for the second eye at the time of the first eye (cataracts) unless there has been as significant change, issue or process involved in the overall care plan.
Modifier -24 is not used on the same day as a procedure, even if after a procedure has been completed, this would (based on documentation) support the modifier -25)
Modifier -24 only impacts the E/M services, not testing services.
Modifier -24 is never used for post operative complications, infections, suture removal or other components of a minor or major procedure that are considered inclusive of that procedure.
This modifier is appended to either new or established patient care E/M services when there is a major procedure performed such as a trauma, retinal tear or fracture.
The purpose of the modifier 57 is to allow payment for both the E/M and the surgical procedure and requires that the documentation of the E/M service goes beyond the basic pre operative assessment and plan.
The modifiers appended to E/M services may result in Medicare and insurance programs audits and review of documentation to assure the support of their use. Things that you can do to make sure the modifiers are used correctly would be:
Use of modifiers can enhance reimbursement but if used incorrectly raise compliance concerns and the potential for Medicare or Insurance program review.