When a provider performs an E/M service and other services including a procedure for the same patient, on the same day, you can code and bill for the procedure and the E/M service separately. You append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service to indicate that the E/M service is separate and distinct from the procedure.
You can also use modifier 25 when a provider performs two E/M services for the same patient on the same day. Append modifier 25 to the second E/M to flag the service as a separate and distinct service from the first E/M.
The documentation in these situations must support the medical necessity of the services and the reporting of a separate E/M.
Prove Separate Services for Modifier Assignment
Medicare and many other payers consider all E/M services provided the same day of a procedure to be part of the procedure; they make separate payment only if an exception applies. Medicare reimburses E/M services separately for these exceptions when the physician appropriately and clearly documents that the service is for a significant, separately identifiable E/M service. Medicare does not require you to submit the supporting documentation with the claim but may request it.
You need to know how and when exceptions apply in order to report both the E/M service and the procedure. The answer is in the documentation. Carefully review the provider’s notes to find the evidence that modifier 25 is applicable. Here are a two of the many clues to look for:
Be aware! Medicare guidance for determination of the same physician states “Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”
Guidance: Peruse CPT® guidelines to help you decide if you are uncertain whether you should report the E/M code. Check the guidelines that precede the non- E/M codes for instruction on including or not including E/M services. Guidance indicates, for example, that a significant and separately identifiable E/M service unrelated to the decision to perform a minor surgical procedure is separately reportable with modifier 25. For a major surgical procedure, you use a different modifier — modifier 57 (Decision for Surgery).
Example: A situation where you can code a separately identifiable E/M is when a provider performs two E/M services for the same patient on the same day. When this occurs you append modifier 25 to the second E/M service to advise the payer that it is a separate and distinct service. For instance, a patient has an office visit for an injury the same day as a preventive visit for an immunization. Report the second E/M for the preventive medicine code with the appropriate level office visit E/M from the range 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient . . .) and attach modifier 25 to this E/M code.
A third party — such as a federal or state agency, employer, social worker, attorney, insurance company, or other regulatory organization — can mandate (dictate) that a patient receives certain services or consultations. You append modifier 32 (Mandated Services) to the procedures or services the third party mandates when you report the services to them for payment. When a third party requires that you perform certain services, you typically can expect full payment for the total amount of the claim you submit unless they have made other arrangements with the provider.
Example: Mandated services can include a request for a second opinion from a separate physician to examine and assess a patient’s health or condition. This type of request may occur over a dispute for a worker’s compensation or disability claim. A consultation is not, however, always a request for a second opinion. Third party requests can be for physicals, evaluations and even procedures.
Caution! Never append modifier 32 to a consultation code for a service that a physician or other clinician asks for, or that the patient or a family member requests. Only the services directly mandated by the third party should include modifier 32.
Snag: Medicare does not accept modifier 32 and will not pay for a service requested by another provider.
Mandated Services Documentation Guidance
Your documentation should include the third party’s request for service, either the written or verbally given request. In addition, the physician performing the service should indicate the services requested and any additional testing and treatment done. The provider typically sends written results of his findings to the third party as well.
A bilateral service is a procedure or service that a provider performs on paired structures, such the lungs, kidneys, breasts, extremities eyes, and ears. You may need to add a modifier to the procedure code when a procedure or service is done bilaterally during the same encounter or visit.
You append modifier 50 (Bilateral Procedure) to avoid coding and billing the same procedure twice. For example, you would code 69200 (Removal foreign body from external auditory canal; without general anesthesia) as 69200-50 rather than 69200-LT and 69200-RT when the procedure is done on both the left (LT) and right (RT) ears. Another example would be when billing for a mastectomy of both breasts as mastectomy procedures are considered unilateral procedures. To report the removal of both breasts you would code one of the CPT® mastectomy codes, such as 19303 (Mastectomy, simple, complete) as a single line item and append modifier 50, or 19303-50.
Look for Bilateral Indicators
There are CPT® codes, however, that are inherently bilateral, and already say that in their description. You should not append modifier 50 to these codes as they are, by definition, already a bilateral service or procedure. For example, 27395 (Lengthening of hamstring tendon; Multiple tendons, bilateral) clearly indicates the code is bilateral.
Still other CPT® code descriptors say unilateral or bilateral. An example of this type of code is 52290 (Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral). If a procedure code indicates the terminology as bilateral — or unilateral or bilateral — as in the two preceding examples, you do not report modifier 50 with these codes.
TIP: The payer dictates how they want you to report bilateral services. Some follow Medicare guidelines as we describe here. Some payers may want to see the same code on separate lines with modifier LT and again with modifier RT to indicate the service or procedure was done to both sides of the body. While another insurer may require that you report a bilateral procedure by indicating the code once without a modifier and then again with a modifier 50. This most clearly illustrates the importance of knowing each of the “payer-specific” requirements.
Automate: To accommodate these various ways of billing, many providers program their CDM to explode or break out the bilateral service into the codes each insurer requires. In this manner, you can enter the code used in our example above (19303-50), and the CDM reports it as 19303-50 to Medicare, 19303-LT and 19303-RT to one independent insurer, and 19303 and 19303-50 to another insurance company.
Multiple services occur when the same provider performs more than one surgical procedure on a patient during the same session or when a patient receives more than one diagnostic service on the same day during the same session by the same provider. You need to use modifier 51 (Multiple Procedures) to identify a Multiple service situation.
In addition to appending modifier 51, you may also need to place the procedure codes in a particular order on the claim form. This is necessary because payers like Medicare and others process multiple procedure claims differently. For example, Medicare will pay 100% of the Medicare-approved amount on their fee schedule or the provider’s charge amount for the first procedure code listed, whichever amount is less. The allowed amount for the subsequent surgical codes is based on 50% of the physician fee schedule amount for each of the other codes.
There are situations where the physician does not perform the full service described in the CPT® descriptor. If there is no other CPT® code available to report the reduced (lesser) service, you use modifier 52 (Reduced services) to indicate that the service was significantly less than usually required.
You can also use modifier 52 for a service or procedure that the physician partially completes and changes to another procedure. For instance, a physician may begin a procedure, complete a portion, but be unable to successfully finish the procedure, so she stops the first procedure and carries out a different procedure, which she successfully completes. You would report the partially completed procedure with modifier 52 and report the second successful procedure with NO modifier.
Note: The physician’s documentation should include the specific reason(s) why a procedure is reduced. This supporting documentation should be sent along with the claim to the insurer for payment.
Caution! You do not submit modifier 52 on E/M codes or with any code that is time-based, meaning that the code descriptor indicates a specific amount of time allowed for the procedure. If there is a reduction in time-based services, then code them with an unlisted procedure code and submit the medical documentation with the claim to indicate the reason(s) for the reduction in the service.
How does the payer handle reduced services? Many payers reduce their reimbursement amount for codes with modifier 52. The provider should not, however, reduce their charge for the service because the insurance would then further reduce their payment on the reduced charge. Bill the full standard charge amount for the service and let the insurance company apply their rules for paying reduced services. Whether or not the insurer reduces the payment amount depends upon the insurance and the situation surrounding each individual case — including how far the physician got in the procedure.
Are you grappling with which modifier to select and when? Do you need help interpreting modifier assignments?
Designed for beginning coders, coding instructors, and as a refresher for experienced coders, Modifiers Explained 2018 jumpstarts learning with an in-depth and easy-to-follow primer on modifiers, including how and when to use them.