Modifiers are important some claims won’t be accepted without modifiers 25 is just one of those cases.
Modifier 25
Significantly separate identifiable E/M by the same physician or other qualified health care professional on the same date as another procedure or service.
Example: office visit for arthritis in the knee, physician gives the patient a corticosteroid injection in the knee.
Coding : E/M with modifier 25, injection
When a physician or other qualified health care professional provides a seperate service in addition to the E/M service. The other service could be done in a totally seperate encounter.
Documentation: The provider should specifically document the E/M encounter as they typically would. The extra procedure or service can be on the same note as the E/M. However, it must stand apart from the E/M note.
Audit note: Many payers are now auditing medical records on claims that have modifier 25. Medical necessity must be met, up to payers’ discretion, the main reason why documentation must be specific and completely thorough!
Modifier 24
Unrelated E/M service by the same physician or other qualified health care professional during a post operative period.
GLOBAL PERIOD: For this modifier, we have to understand global periods. The time around a surgical period. Global period depends on the surgery being done. There are 3 global periods; 0 days, 10 days, 90 days. Global period includes a preoperative E/M the surgery day and post operative visits. Global period starts the day the decision for surgery is made.
Example: a patient has a 90-day global period knee arthroscopy on the right side and presents to the same doctor because her left side is stiff and hurting. The doctor examines the patient ordering x-rays and determines the pain is most likely the starting stage of arthritis but offers to inject the knee with a corticosteroid as a first treatment option.
Coding: code the office visit and put modifier 24 on the code to tell the insurance that the encounter is unrelated to the surgery, and should be paid outside of the surgical global period
IMPORTANT: The modifier should only be used if it is the same physician who did the surgery seeing the patient for an unrelated issue.
If working in a group practice, the physicians working in that specialty is considered one physician and can use the modifier.
Qualified health care professional is a nurse practitioners or physician assistants
When physicians get credentialed, they are known as their specialty i.e pediatrician, internist, surgeon, cardiologist… when qhp get credentialed, they are not considered specialists, just a general practitioner. When billing for a QHP, it can get tricky because they are the same as family medicine physicians. Even if they are working as a PA in orthopedics, they are not specially credentialed for orthopedics, just general medicine.
When to use Modifier 24
When the surgeon is seeing the patient during the global period for something unrelated to the surgery
When another physician of the same group same specialty (orthopedics, cardiology, vascular surgery, plastic surgery, OBGYN…) sees the patient for an issue unrelated to the surgery performed by a partner of their same group, same specialty.
Always check with the coding guidelines as well as payers guidelines for the most up to date correct information.