Modifiers are crucial in telling the story of the claim by identifying procedures that have been altered in some way without changing the core meaning of the code(s) submitted. Let’s look at the modifiers that can be appended to evaluation and management (E/M) codes used within the global period.
The Global Surgical Package
Understanding global modifiers begins with a comprehension of the global surgical package. The CPT® surgical package definition indicates that for every surgical procedure, there are integral services included that cannot be reported or billed separately, as indicated in Example A.
The Centers for Medicare & Medicaid Services (CMS) refers to the surgical package concept as the “global period.” In minor procedures, such as removal of skin lesions or endoscopies, a zero- to 10-day global period after the procedure applies. For major surgeries, the global period is extended to one day prior to and 90 days after the procedure. An example of a major surgery would be an appendectomy. Note that commercial carriers may place different global periods on procedure codes.
One way to determine the global period for Medicare is by using the Medicare Physician Fee Schedule Database (MPFSDB). Global surgery status indicators are attached to each procedure code from the surgery section of CPT®, as shown in Example B.
Modifiers 24, 25, and 57 (see descriptors below) can be appended to E/M codes, which include CPT® 99201-99499, and ophthalmology codes 92002-92014; the latter codes are found in the medicine section of CPT®.
Modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period shows the E/M being billed is not part of the global surgical package and is separately reimbursable. To further indicate the procedure is unrelated, we usually—although not necessarily—use a different diagnosis from that linked to the previous procedure.
For example, on May 1, the patient undergoes an appendectomy for acute appendicitis. The appropriate coding based on this information is 44950 Appendectomy with 540.9 Acute appendicitis; without mention of peritonitis. On May 19, the patient presents to the same operating surgeon with a new onset of right upper quadrant (RUQ) abdominal pain. At this visit, the surgeon examines the patient and suspects cholecystitis. He orders a complete blood count (CBC) and abdominal ultrasound, and documents an expanded problem-focused history, expanded problem-focused exam, and medical decision-making of low complexity.
The appropriate coding on May 19 is 99213-24 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity … with a diagnosis of 789.01 Abdominal pain; right upper quadrant. Modifier 24 is appended to indicate that this E/M is unrelated to the previous surgery. Notice the use of different diagnoses.
In this next example, it is appropriate for the same diagnosis to be used for both the surgery and the subsequent E/M service: On June 1, the patient presents for a closed treatment of a single metacarpal fracture in his left hand. The appropriate coding is 26600-LT Closed treatment of metacarpal fracture, single; without manipulation, each bone, which has a 90-day global period. Modifier LT Left side is appended to indicate location. The diagnosis is 815.03 Fracture of metacarpal bone(s); closed; shaft of metacarpal bones(s).
On July 1, the patient presents to the same operating surgeon, complaining of a possible fracture in his right hand. The physician performs an expanded problem-focused history and exam and his medical decision-making is of low complexity. After review of the X-rays, which may be separately billable, the physician identifies a new metacarpal shaft fracture. The appropriate coding is 99213-24, with 815.03. Note the use of the same diagnosis. Modifier RT Right side for the right hand would not be appropriate for the E/M code.
Append modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to indicate that an E/M service is separate from what is normally required for a minor procedure. There must be a clearly documented, distinct, and significantly identifiable E/M service, above and beyond the usual preoperative and postoperative care associated with the procedure. The CPT® description of modifier 25 specifies, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service on the same date.”
For example, an established patient presents to the office complaining of left eye pain and feeling as if sand is in his eye after doing some repair work around his house. The physician performs an examination, finds a wood splinter in the cornea, and removes it. He documents a problem-focused history and exam and straightforward medical decision-making. The appropriate coding is 99212-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making … and 65220-LT Removal of foreign body, external eye; corneal, without slit lamp with 930.0 Corneal foreign body.
Alternatively, for an eye examination, report 92012-25 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient and 65220-LT.
Modifier 25 for Combo Sick/Well Visits
Modifier 25 also may be used when a preventive service (well visit) and a problem-oriented E/M (“sick visit”) occur during the same encounter. CMS instructs, “Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology codes 99201-99215) billed at the same visit as the Annual Wellness Visit (AWV) when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.” (https://questions.cms.gov/)
In this instance, be sure the documentation can substantiate two distinct E/M codes. One visit would be measured by the key components of history, examination, and medical decision-making (or, possibly the time component). The other service needs to indicate a full preventive care service. The modifier is appended to CPT® problem-based codes. Keep in mind that commercial payers’ policies vary. Some will not pay for two E/Ms on one date of service and some payers may reduce the amount of the second E/M reimbursement. It is important to check with the payer to verify both the coding policy and the patient’s benefits.
For example, a 35-year-old established patient had previously scheduled an appointment for a routine examination. On the day of the appointment she injures her ankle. The documentation of the visit supports a problem-focused history related to the ankle injury, a problem-focused examination of the ankle, and medical decision-making of straightforward complexity. The documentation also separately supports a comprehensive preventive medicine E/M service.
The appropriate coding of this service for a commercial payer is 99212-25, with a diagnosis of 845.00 Sprains and strains of ankle; unspecified site. You would also report 99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years with a diagnosis of V70.0 Routine general medical examination at a health care facility.
For Medicare, there are several options for reporting the wellness exams:
- For a Medicare Initial Preventive Physical Exam (IPPE), use HCPCS Level II code G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment.
- For a Medicare AWV, use HCPCS Level II code G0438 Annual well visit; includes a personalized prevention plan of service (PPS), initial visit for a new patient or G0439 Annual well visit; includes a personalized prevention plan of service (PPS), subsequent visit for an established patient.
For clarification of the Medicare IPPE and AWV guidelines, see the Medicare Claims Processing Manual chapter 12, 188.8.131.52, “Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV).”
Whether reporting to commercial payers or Medicare, the use of different diagnoses for sick and well visits further differentiates the services.
Modifier 57 Decision for surgery is similar to modifier 25, except that the surgical package includes one day prior to the procedure and usually has a 90-day global period after the procedure. Note: The CPT® description of the modifier does not actually indicate a global period, but most payers’ guidelines indicate use for a major global period. The E/M may be for the same or for a different diagnosis than the surgery.
Remember CPT® surgical package guidelines include one related E/M encounter subsequent to the decision for surgery. So, if the operating physician performs an E/M on the day before a previously scheduled surgery that includes normal preoperative care for the surgery, the E/M is not separately reportable because it is included in the global package. If the operating physician sees the patient the day before the surgery and at that visit decides to perform surgery, however, modifier 57 can be properly appended to indicate the E/M is not “bundled” into the surgery because a decision for surgery was made at this visit.
For example, a non-Medicare patient presents to the emergency department (ED) with acute right, lower-quadrant abdominal pain and fever. The ED physician requests a surgical consult. The consulting surgeon documents a level 3 outpatient consult and decides at that visit to perform an emergency appendectomy.
The appropriate coding is 99243-57 Office consultation for a new or established patient … , 44950, and 540.9.
Note: The global period of the performed procedure determines whether it is appropriate to append modifier 25 or modifier 57 to the E/M code.
Nancy Clark, CPC, CPC-I, is a member of the 2011-2013 AAPC National Advisory Board (NAB). She is director of the Healthcare Business Resource Center in New Jersey. She also She also is a PMCC-approved instructor and a health care consultant. Ms. Clark participates in the Novitas Medicare Provider Outreach and Education Advisory Group.