Learn proper coding for modifiers 59 and 25

Recently, ACP has received several member inquiries regarding the use of CPT modifiers 59 and 25 in conjunction with evaluation and management (E/M) codes. The two modifiers are very similar, but not interchangeable. Because they are so similar, many physicians unintentionally miscode their claims and then have to deal with challenging the denials later. This article will explain how to decide which modifier is appropriate.

Modifier 25

The first modifier to consider is 25. Its complete definition, defined by the American Medical Association Current Procedural Terminology 2012, is “a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.”

The keys here are “E/M service,” “above and beyond,” and “same physician on the same day.”

As an example, modifier 25 will be used when the physician performs a minor surgical procedure on the same day as an E/M service. The physician will need to provide separately identifiable documentation of the components of the E/M service and of the non-E/M service.

Documentation must be extensive enough that the additional service is readily identifiable to auditors who might review the claim. The E/M service must require additional history, exam, knowledge, skill, work time and/or risk above and beyond what is usually required for the procedure, and these must be included in the documentation.

None of the E/M service's documentation components may also support the performance of the procedure itself; there must be separately identifiable documentation to report the procedure.

A second example would be if the physician performs an initial or subsequent Medicare Annual Wellness Visit (coded as HCPCS codes G0438 or G0439) to establish or maintain the patient's personalized prevention plan, and also provides an E/M service (CPT codes 99201-99215) for a medical condition on the same date of service. Then, the physician must add modifier 25 to the medically necessary E/M service, to be reimbursed for both services. The same coding logic applies when an Initial Preventive Physical Examination (IPPE) is provided on the same date as a medically necessary E/M service.

Both services must be fully documented. CMS cautions that the elements of the Annual Wellness Visit should not be included in the documentation for the E/M service if only for the purpose of generating a higher intensity code. It is critical to note that some of the components of a medically necessary E/M service (such as a portion of the history or of the physical exam) may have actually been part of the IPPE or Annual Wellness Visit. In that case, those elements should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable E/M service.

As always, medical decision making and clinical complexity are the important factors when selecting the appropriate code.

Modifier 59

Modifier 59 identifies procedures or services that are not normally reported together. The full definition of modifier 59, again from the AMA's CPT 2012, is:”Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. 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. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or the area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. 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.”

To appropriately use modifier 59, physicians should not use it on an E/M service code. When billing for an E/M service and a procedure that is not typically included in an E/M visit, or is not typically done on the same day, physicians should use the 59 modifier on the non-E/M service code.

Modifier 59 should be used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury.

It should also be used when an intravenous (IV) protocol calls for two separate IV sites. It will indicate the second initial injection, or when the patient has returned on the same date of service for a separately identifiable service.

Finally, modifier 59 should be used when no other existing modifier applies to distinguish appropriately billable services.

Modifier 59 and the NCCI edits

The National Correct Coding Initiative (NCCI) edits, built into the Medicare contractors' claims processing systems, control improper payment of Part B claims by disallowing co-billing of certain combinations of CPT codes. With the NCCI edits, the coding gets a bit trickier because CMS forces modifier 59 to operate in ways contrary to its original design.

For the NCCI edits, CMS recently clarified in a MedLearn Matters article (see sidebar on page 8) that the main purpose of modifier 59 is to “indicate that two or more procedures are performed at different anatomical sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationship of the two or more procedure codes.” This is different from the way CPT defines modifier 59.

In other words, a physician can use modifier 59 to bill the secondary, additional, or lesser procedure in an NCCI edit combination. If the edit shows indicator “1,” modifier 59 can be used to communicate to the payer that the two billed services or procedures were appropriately performed together in that circumstance, such that either of the following is true:

• The procedures were done at different anatomic sites on the same date or
• The procedures were done during different patient encounters, for the same patient, by the same physician, on the same date.

In this way, modifier 59 is essentially a tool to bypass or override the NCCI edit.

There are relatively few NCCI edits that involve E/M services, but here are two examples:

• If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with psychological testing (such as CPT code 96101), modifier 59 would be appended to the testing code.
• If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with a demonstration of home monitoring of a patient's international normalized ratio (e.g., HCPCS code G0248), modifier 59 would be appended to the demonstration code.

The overall effect of modifiers is to alert the payer to acceptable deviations from the CPT coding rules. The modifiers will not be used on all claims; the popular wisdom is that modifier use will be the exception rather than the rule. But there will be times when a modifier is needed. In all cases, physicians should remember that the documentation must show that the two services were separate and distinct.