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E&M Modifiers
What Is a Modifier?
A modifier is a two-digit qualifier that is appended to a Current Procedural Terminology (CPT) code that provides additional information when submitting a claim to the carrier for reimbursement. A modifier may be used to indicate:
- A service or procedure has both a technical and professional component.
- An increase or reduction in a service or procedure.
- A service or procedure has been performed by more than one provider.
- The service or procedure was rendered in more than one location.
- Only part of a service was performed.
- A bilateral procedure was performed.
- A service or procedure was performed more than once.
- An unusual event occurred during a service or procedure.
The Modifier Reference Guide  lists Level I (CPT-4), and Level II (non-CPT-4 alpha numeric) modifiers. Level I and II modifier definitions are contained in the Healthcare Common Procedure Coding System (HCPCS).
Evaluation and Management (E&M) Service Resulting in the Initial Decision to Perform Surgery
Evaluation and management (E&M) services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery, and, therefore, may be billed and paid separately.
In addition to the CPT E&M code, modifier 57 (decision for surgery) is used to identify a visit which results in the initial decision to perform surgery.
If E&M services occur on the day of surgery, the physician bills using modifier 57, not 25. The 57 modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.
Significant E&M on the Day of a Procedure
Modifier 25 is used to facilitate billing of E&M services on the day of a procedure for which separate payment may be made.
It is used to report a significant, separately identifiable E&M service by the same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patient’s condition required a significant, separately identifiable E&M service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. This circumstance may be reported by adding the modifier 25 to the appropriate level of E&M service.
Unrelated Visits During the Postoperative Period
Modifier 24 was established to simplify billing for visits which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure.
Report an unrelated E&M service by the same physician during a postoperative period. The physician may need to indicate that an E&M service was performed during the postoperative period of an unrelated procedure. This circumstance is reported by adding the modifier 24 to the appropriate level of E&M service.
Services submitted with the 24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery. An ICD-9-CM code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable documentation.
The following modifiers can ONLY be appended to E&M services:
| 24- |
Unrelated E&M Service, Same Physician, During Postoperative Period: The physician may need to indicate that an E&M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. |
| 25- |
Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need 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 and postoperative care associated with the procedure that was performed. 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 the E&M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E&M service. |
| 57- |
Decision for Surgery: An evaluation & management (E&M) service that resulted in the initial decision to perform the surgery. |
CPT codes, descriptions and other data only are copyright 1999 American Medical Association (AMA) (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.
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