Costly Mistakes to Avoid When Using CPT® and CMS Modifiers

To Capture More Revenue, Master These Commonly Misused Modifiers

Despite the thousands of codes in the CPT® codebook (10,155 of them in 2018), you still won’t find one to fit every possible circumstance. That’s when you need to know how to use CPT® and CMS modifiers to ensure you’re properly reimbursed.

What are modifiers? They are two-digit codes designed to communicate how specific circumstances changed a given service or procedure without changing its definition or code. Level I (CPT®) modifiers are two numbers. Level II (CMS/HCPCS) modifiers are either two letters or are alphanumeric. Modifiers make your claims more accurate and convey details affecting how much you should be paid for your work.

But as useful as they are, they can also be confusing. As you’ve no doubt found out in your own practice, misused modifiers can lead to coding and billing mistakes that end up costing you time, effort, and money to fix.

At MDCodePro, we’re committed to helping healthcare providers become more efficient, productive, and profitable. That’s why we’ve pulled together this list of a few CPT® modifiers practitioners often find problematic. (We’ll examine some troublesome CMS modifiers in a future blog post).

We hope you’ll use these tips to avoid some coding and billing pitfalls tripping other providers up.


A Brief Guide to Frequently Misused CPT® Billing Modifiers

Modifier 25

In 2017, CMS flagged potential Modifier 25 misuse as cause for concern.

The agency noted 19% of codes for 0-day global services—services whose valuation already includes routine evaluation and management (E/M)—were billed with Modifier 25 more than half the time.

Modifier 25 may still be causing as many problems as it did in 2005, when a notable OIG report found 35% of claims using it failed to meet Medicare requirements, resulting in $538 million of improper payments.

The CPT® manual defines Modifier 25 as “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.” So when weighing whether to use it, focus on the word “significant.”

cms modifiersNot every additional service you decide to perform on the same day as another warrants this modifier. The service must be “above and beyond” what’s normally required. For example, coding consultant Emily Hill points out Modifier 25 sometimes properly distinguishes E/M service from an actual injection or drug administration, but “some immunization codes include counseling the patient.”

“A knowledgeable individual, looking at the available documentation,” writes the AAPC’s John Verhovshek for Physicians Practice, “should be able to identify the important E&M components of history, exam, and medical decision-making (MDM), apart from any other procedures or services performed on the same day.”

To use Modifier 25 correctly:

  • Make sure your documentation supports the service as significant, medically necessary, and separately identifiable.
  • Double check that the same provider (including different physicians in the same group practice) performed the service.
  • Append Modifier 25 only to E/M codes, not procedure codes.
  • Consider using Modifier 25 instead of Modifier 59, which shouldn’t be added to E/M services, but often incorrectly is.        

Modifier 24

Providers often overlook Modifier 24, according to Emily Hill, but it can come in handy. It identifies an “[u]nrelated E/M service by the same physician during a post-operative period.”

The key word in this definition is “unrelated.” Medicare doesn’t allow separate billing for post-op medical and surgical complications unless they require another trip to the OR, as coding expert Betsy Nicoletti writes for Physicians Practice.

To use Modifier 24 correctly:

  • Make sure your documentation shows you performed the medically necessary service solely to treat the underlying condition, and not as part of routine post-operative care included in the surgical package.
  • Keep a list of office-based procedures’ global periods readily accessible to help you remember whether you should append a modifier.
  • Don’t confuse Modifier 24 with Modifier 79, which identifies unrelated non-E/M services or procedures.

Modifier 57

Modifier 57, “Decision for Surgery,” applies to an initial consultation or evaluation in which the physician determines a major surgical procedure (one with a 90-day global period) is necessary.

Providers sometimes mistakenly apply Modifier 57 when Modifier 25 is the right choice. But Modifier 57 does sometimes belong together with Modifier 24. Use both when when the E/M service leading to the decision for surgery occurs in the post-op period of another, unrelated procedure.

To use Modifier 57 correctly:

  • Reserve it for major procedures—rely on Modifier 25 for minor ones.
  • Be certain your documentation supports the decision for surgery itself, not just your pre-operative clearance of the patient for surgery.
  • Don’t use it to flag decisions for elective surgeries, since those decisions usually happen during previous outpatient visits.

Modifier 26, TC, PC

Some services and procedures pose complicated coding questions because they contain both a professional component (PC: supervision, interpretation, and reporting) and a technical component (TC: costs of equipment, supplies, and necessary technical support, as well as practice and malpractice expenses).

If a single physician or practice performs both parts of a two-component procedure—for example, a doctor at an independent clinic orders and reviews an X-ray taken on-site—a single, global CPT® code will suffice. But in many cases, separate PC and TC payments are in order, such as when a physician interprets a test administered at another facility.

When added to a CPT® code, Modifier 26 indicates you provided the service or procedure’s professional component only.

To use Modifier 26 correctly:

  • Avoid using it with standalone CPT® codes that already indicate professional-component or technical-component-only services.
  • Don’t get confused and use CMS Modifier PC to designate a professional component; this modifier means the wrong surgery was performed on a patient.   


Modify Your Documentation by Making it Stronger

Misusing either CPT® or CMS modifiers can seriously snarl payment of your claims, and could also cause considerable financial pain if auditors bring compliance issues to light.

As is often the case in medical coding, one of the best ways you can guard against mistakes is to ensure your documentation is as accurate and comprehensive as possible. And one of the best ways you can achieve that goal is by making the MDCodePro app an integral part of your practice:

  • Its short, online video lectures offer you a streamlined understanding of CMS billing regulations.
  • Its easy-to-follow documentation method, validated by numerous audits, makes sure you’ll always be able to support a visit’s optimal CPT® code.
  • Its step-by-step code generator finds those optimal codes for you, based on the information you provide.

Why not start modifying your documentation now for higher efficiency, productivity, and profitability? Fill out this form to get more details about how MDCodePro can help you.

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