22 Mar 2015

MODIFIER 24, 25 & 57

Modifier - 24, 25 & 57
 are used only with E&M codes under various circumstances are described below with some common example,


 Modifier 24 - Unrelated Evaluation and Management by the same physician during a postoperative period.


        When an unrelated E/M service is performed by the same physician during the postoperative (global period -10 or 90-day postoperative period) then append modifier 24 to the E/M procedure code.


       Eg: A surgeon performs Puncture aspiration of abscess - CPT 10160 on 1st Jan 2014 which is 10 days of global period surgery.


          And the same patient returns on 5th Jan 2014 for some other reason apart from the previously performed surgery eg: abdominal pain, Then we should report this E&M service with modifier 24.


Note: Make sure that we are not assigning the same diagnosis code which is the reason for the surgery which was performed earlier, and then there would be a chance of claim get denied.


Eg:  DOS: 1st Jan 2015

        First Procedure: 10160            Dx. Abscess in leg


Eg: DOS: 5th Jan 2015

       Within the global period for another reason: 99214 - 24    Dx. Abdominal pain


Exception - When the patient returns on 5th Jan 2014 for the same reason related to previous surgery for a checkup or follow up then we should assign CPT 99024 (Postoperative follow-up visit) instead of adding modifier 24.


Eg: DOS: 1st Jan 2015

       First Procedure: 10160          Dx. Abscess in leg


Eg: DOS 5th Jan 2015

       Within the global period for the same reason: 99024     Dx. Abscess in leg



Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the same physician on the same day


When a minor surgery (0 days or 10 days global period) was performed on the same day along with E&M service then append modifier 25 to the E&M procedure code.


Eg: A surgeon performs 10160 and E&M on 10th Feb 2015, Report E&M with modifier 25.


DOS: 10th Feb 2015

Procedure:   99214 - 25




When 2 E&M services were performed on the same day, under this circumstance, we can assign modifier 25 with the first listed E&M


Eg: E&M and Preventive visit were performed on the same day 5th Feb 2015, Report first E&M service with 25 modifier


DOS: 5th Feb 2015

Procedure:  99213 - 25




Note: When the E&M is performed with Radiology and pathology section on the same day then we should not append modifier 25 with E&M.


We should append modifier 25 with E&M when surgery codes or some of the medicine section codes being assigned on the same day with E&M service.


Eg: E&M and vaccine codes were performed on the same day, Then report E&M with modifier 25


DOS: 1st April 2015


Procedure:  99212 - 25





Modifier 57 - Decision for surgery.


When a major surgery (90 days global period) performed with E&M on the same day or a day before, (In both these cases, the E/M service is provided by the same physician, either the day before or the day of major surgery) Append modifier 57 to the E&M procedure code.


E.g. A surgeon performs E&M and 21820 (Closed treatment of sternum fracture) on 1st Mar 2014 which is 90 days global period, Append modifier 57 to the E&M.


Eg: DOS: 1st Mar 2014

       Procedure: 99215 - 57



Global periods:


10 days:  Day of surgery - Next day/Postoperative day 1 to 10 days immediately following the date of surgery


 90 days:  One day before the day of surgery - Day of  surgery - Next-day / postoperative day 1 to 90 days immediately following the date of surgery.


CPT 99024:


When to use CPT 99024 Instead of Modifier 24?


When the patient returns back to visit the same physician who has performed 10 days or 90 days of global surgery for the patient and the reason for the visit is related to the surgery, We should use CPT 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure)


When we can append both 24 and 25 modifiers with the E&M?


When the E&M falls within the 10 days or 90 global periods and there are 10 days global surgery is performed on the same day. Then we should use both the modifier (24 and 25) with the E&M.


Eg:   DOS: 1st Jan 2015

         Procedure: 99214 - 57



21820 is 90 days global procedure hence we appended modifier 57 with the E&M since it is 90 days global whatever the procedure has been performed within the next 90 days from the date of surgery (1st Jan 2015) then we have to check whether it’s for the same reason then we should use CPT 99024 and if it’s for the different reason not for a checkup or follow up then we should append modifier 24 with the office visit.


        DOS: 1st Feb 2015

        Procedure: 99213 - 24, 25



In the above scenario, The E&M falls within the Global period hence we appended modifier 24 and there is a same day minor surgery hence appended modifier 25 also. 


We have to understand the basic concepts of modifier 24, 25 and 57 and when to use and where to use which modifier to use is very important for the coders to avoid unnecessary denials. We have to go back and check the patient history for any previous 10 days or 90 days global procedures were performed or not to append modifier 24.


Some other modifiers which we are using during global periods are Modifier 78, 79 and 58 are with the surgery codes not with the E&M codes.