Modifer 25 and 59

We are training several new employees right now. Glad to be expanding, progressing as expected, blah, blah, blah. But they are having a great deal of trouble with understanding when to use the modifiers 25 and 59. If we are having issues in here, some of you out there might be as well, and I want to make your life easier. First, for you technical types here are the exact descriptions from the CPT book.

Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service:
It may be necessary 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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). 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 services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Modifier 59 – Distinct Procedural Service:
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Now for some practical application. The modifier 25 goes on the office visit.  Here are the situtations in which you need a modifier: 1) If a patient gets a procedure on the same day as an office visit, 2) medication injected same day as an office visit, 3) pap smear done same day as an office visit, 4) physical done same day as an office visit. Don’t worry, we’re about to go through and lay out how we are supposed to use them.

If you need to bill an office visit and a procedure, you would use a modifier 25 on the office visit line. A procedure counts as any CPT code between 10000 and 69999. Plus, you need a different diagnosis on the procedure than you have on the office visit. Here is an example:

A patient comes in with ear pain and the doctor diagnoses her with an ear infection and does an ear lavage. If you want to get both the 99213 and the 69210 paid on the same visit here is how you would enter that charge:

Ear pain/otalgia (ICD9 388.70) (ICD10 H92.09)           99213  –  25

Ear infection (ICD9 382.9) (ICD10 H66.90)                   69210

When you put it in with a different dx on the office visit and  a 25 modifier the insurance will pay each line item separately.

Paps and physicals work in a similar way. The medical dx go on the office visit and the V-codes go on the preventive service. I could write a whole post on paps (and probably will) but we are going to keep it simple here.

465.9 (ICD10 J06.9)    462 (ICD10 J02.9)                      99213  –  25

V70.0                                                                               99395

When you need to bill an office visit and an injection on the same day, you have two options. The cpt 96372 is for an intramuscular injection of a J-code. You can bill the office visit and the substance all day and they will all get paid separately with no modifiers. The injection administration is what the insurances like to include in the office visit. However, you will get paid about $20.00 for each administration billed correctly and that can add up. Say a patient comes in with knee pain and the doctor diagnoses him with osteoarthritis and wants to give him an injection of Toradol. You put the symptom on the office visit with a 25 modifier and the substance and the admin have the condition. Then, you put a 59 modifier on the 96372. So, it would be three line items and it would look like this:

Knee pain       719.46 (ICD10 M25.569)                        99213  –  25

Osteoarthritis  715.96 (ICD10 M17.9)                            J1885

Osteoarthritis  715.96 (ICD10 M17.9)                            96372  –  59

I have attached an Updated modifier chart that will tell you when a service needs a modifier. We printed this out and gave it to all the new people and it seemed to clear up most of the confusion.

As always, call or email if you have any specific questions about something that didn’t make it through here on the blog.



Filed under Billing, Claims, CPT, Health Care, ICD9, Medical Billing, Modifiers

19 responses to “Modifer 25 and 59

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  2. A patient comes in with ear pain and the doctor diagnoses her with an ear infection and does an ear lavage. If you want to get both the 99213 and the 69210 paid on the same visit here is how you would enter that charge:

    01/09/13 388.70 (ear pain/otalgia) 99213 – 25

    01/09/13 382.9 (ear infection) 69210

    Can you explain this more detail to me ?

    • If you want to be able to get the office visit and the procedure paid on the same day, you need to have a different diagnosis on the office visit then you do on the procedure. So, use the symptom (the ear pain) on the office visit, and the reason for the ear lavage (the infection) on the ear lavage. That way the insurance company will pay for both services.

  3. Emily

    What if you have an E/M service., Wellness Visit and injection done on same daY?

    • We put the modifier 25 on the office visit with the medical diagnosis. We use the V70.0 (or V20.2) with the preventative code, and then we make sure the injection has a different diagnosis than either of those codes and use a 59 on the 96372. So it would look like this:

      724.2 723.1 99213 25
      V70.0 99395
      846.0 847.0 J1885
      846.0 847.0 96372 59

      90% of the time, we get paid for all line items. Sometimes the insurances want us to send in notes to justify that, but as long as the doctor documents everything in detail, we don’t have a problem getting it paid. If you need more help or a more detailed explanation, you can call me at (909) 374-5439.

  4. Tracy Graham

    What about the guidelines regarding not coding for a symptom that is an integral part of a disease/illness? Such as in your example above with the earache. Ear pain is/can be a symptom of OM so you would not code it. Or are you saying we code ear pain on the O/V, and code the OM on the injection of the antibiotic or ear lavage as in your scenario?
    Thank you!

    • Tracy,

      If a provider does a procedure and only gives me one DX, I do code the symptoms on the office visit, like in my scenario. Occasionally, the insurance will want to see a copy of the office notes, yet even with that they end up paying the whole claim. The patient’s chief complaint would be the pain. That is what prompted the exam, the office visit. The doctor’s professional opinion that the pain is a result of OM is why he did the ear lavage. And that is how I have successfully appealed bundling to various insurance companies.

      One of the ladies I work with doesn’t bother managing the DX. She uses the same DX on the office visit as she does on the procedure. And she still puts a 25 modifier on the office visit. Her claims still often get paid. Not 100% of the time, but some do get paid. Personally, I don’t like that method for two reasons. 1 – It is not 100% effective, and 2 – because the 25 modifier is telling the insurance that the procedure should be paid separately from the office visit because it is unrelated. If we put the same DX on both lines, that is specifically stating we did both services for the same reason.

      Since our only other option is to let the doctor eat the cost of either the exam or the procedure, I will stand on my logic when I argue with the insurance, even if it is a bit shaky. And thanks for the feedback!

  5. Jeneva Johnson

    So if you bill 99395 with z00.00 and 69210 you wouldn’t bill the same dx on all line items? You would bill only the dx that fits that procedure with that line item?

    • I would only bill the DX that fit each procedure. A lot of offices use all the DX on all of the lines and simply put the 25 modifier on the exam/preventative portion, and that does get paid a portion of the time. But I have found that separating the DX gets me far more consistent payment.

  6. Jeneva Johnson

    Can you bill 69210 and 85610 together? modify? patient did not see a provider, just came in for the was and INR check.

    • I don’t see why not. Those are not services that would generally overlap. I think that you would be just fine billing those together, especially since you said there is no office visit. Have you received any denials?

  7. Carla

    I apologize but I do not agree what so ever with the ear lavage example. I understand what you were trying to imply, but it’s not a good example. If a patient comes in for ear pain and is diagnosed with otitis media or otitis externa, the correct code to use is the final diagnosis code. Ear pain is a symptom of the ear infection. Also, from a clinical stand point, a physician would not irrigate an infected ear. That would cause the patient more pain and discomfort making the infection worse. I am a Certified ENT Coder and modifier 25 was commonly used by my surgeons. After extensive research, webinars, seminars and speaking with well known consultants in the industry I was finally able to confirm and understand how modifier 25 should be used. With that being said, I am also disagreeing with your statement that 2 diagnosis codes are required. According to the National Correct Coding Iniative Policy Manual it states that “the e/m service and minor surgical procedure DO NOT require different diagnosis.” For example, the patient comes in with a chief complaint of ear fullness and dizziness, after performing the exam and obtaining consent the physician decides to perform an impacted cerumen removal then you would only bill the procedure code 69210. However, due the nature of the presenting problem he completes a full neuro exam the documentation validates the medical necessity then you can bill your OV code along with mod 25 69210. This is where it gets tricky for coders because a nurse or an LPN can see that there’s a possible underlying condition that hasn’t been diagnosed yet. This is the easily but not so easily inferred part. This would be considered a separately identifiable issue.
    One last thing, and I in no shape or form am I trying to offend you. However, I strongly believe that providing feedback to fellow coders is important since our credibility is on the line. I have yet to find a credible resource where it states that you can use the patients chief complaint as a diagnosis? The patient cannot diagnose themselves, unless the physician agrees with what the patients complaint is. I can go to the doctor and say my head has been hurting for 1 week non stop, based on his assessment he recommends I take a pregnancy test and I’m pregnant. Which explains the headaches, so you would use the positive pregnancy results diagnosis. My whole point is as coders we have to be really careful how we present information. I tell all my surgeons whenever they Ask questions in regards to coding we don’t ever want to lead them into coding a high level or an additional procedure. We want to lead them Into documenting based on the nature of the presenting problem which leads the way to medical necessity. That is the key. I always tell them I cannot provide them with an answer to their detailed coding question, but I can certainly provide the documentation requirements. We have to stop speaking to them and others in monetary terms “this modifier pays this if you bill it like this” that is one of the reasons why there is so much fraud, abuse and waste. It makes it difficult for coders like myself to be taken seriously, because of the experiences that people have had with receiving inconsistent information. I don’t know it all, but I will find out. The most important thing for me is my integrity and reputation.

    Carla F Acevedo, CPC, CENTC

    • I approved your comment because I would like people to see that there is no “ONE RIGHT WAY” to do things. My advice is based on my experience with ACTUALLY getting things paid. I appreciate the perspective of a certified coder, but we have received denials when we bill a procedure and an office visit with the same diagnosis and a 25 modifier. The insurance states that the modifier does not apply and the charges end up being bundled. I used the example of an ear lavage, because I, personally, received an EOB with bundled services for an office visit and ear lavage, and this was how I submitted the corrected claim and the insurance reprocessed and ended up paying both line items. If you don’t use a separate diagnosis on the office visit, you won’t get this denial every time but it happens enough that we send our claims out with managed diagnosis.

      As a biller, my responsibility is to the doctor. To getting my doctors paid the maximum amount that I can for their services. My sister company and mine are the best in the area and have made our reputation on increasing collections and bringing in the maximum reimbursement for our practices. I will never do anything illegal, but blindly following guidelines for the sake of following guidelines, is not in my doctor’s best interest. It’s like paying taxes you don’t have to pay. You can be sure the insurance companies use every rule and loophole to pay the least amount they can on a claim. I am using the insurance companies’ own rules to my providers’ advantage. I will always speak to my doctors in monetary terms, because they are small business owners like me and they deserve to be well compensated for their services.

      Also, when a patient has pain, the pain is a valid diagnosis. A physician does not have to agree with me that my ear hurts for the code to be otalgia. A physician does not have to agree with me that my head hurts for the code to be headaches. Those are valid ICD10 codes and the doctor would be remiss if they were not included in the assessment. Especially because medicine is as much an art as it is a science. The doctor will decide a diagnosis based on education, observations, and past experiences rather then based on an omnipotent nature. Doctors are not always right, even when it comes to something as seemingly innocuous as a headache or ear pain, and coding the symptoms that led them to their opinion can be invaluable when those records need to be reviewed.

  8. Having issues with BCBS AL for claims like the following example:
    patient that has 2 diagnosis’, The provider examines patient and chooses office visit 99213, J1100, 96372 AND 69210 in the EHR.
    Is it correct to bill 99213-25 J1100 & 96372 for 1st diagnosis then 69210-59 with 2nd diagnosis?

    • Robyn, in my experience, if I don’t put the modifier -59 (or XU) on the 96372 for BCBS, my 96372 is denied. The 69210 doesn’t need a -59. It should get paid as long as you separate the office visit with the -25 modifier, as in your example. And you will most likely get paid for all four codes if you set the diagnosis up the way you have indicated and put the -59 on the 96372.

  9. Aguero

    I have some charges where we bill an OV w inj. and well exam. We add a 25 mod on OV and a 59 w the 96372 but our well exam doesnt get paid. Could you help explain why or how i could bill so my well exam can get paid.

    • The well exam needs a 25 modifier as well. So you would end up with two 25 modifiers, one on the office visit, one on the well exam. You would keep your 59 modifier on the 96372. The well exam is probably getting bundled with the 96372 right now, and, of course, the insurance pays the code with the lower allowed amount. If that doesn’t work, I have a template appeal letter that you can use along with a copy of your office notes to get the well exam paid separately.

      Usually just billing the two line items both with modifier 25 works.

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