CPT Code Modifiers: Clarification of Commonly Used and COVID Updates

There are many circumstances when coding more than one Current Procedural Terminology (CPT) code on the same encounter that clarification is needed regarding whether to use modifier 25 or 59. Should it be added to the Evaluation and Management (E/M) visit or the procedure code? Which modifier goes on which code? Here is the answer: Use the 25 modifier for the E/M codes and the 59 modifier for the procedure codes.

MODIFIER 25 AND 59

Modifier 25 is used for “a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.” For example, a patient arrives at the doctor’s office for a biopsy of a skin lesion, and during the visit, the patient also asks the physician for a prescription for an upper respiratory infection. The modifier would be appended to the E/M code for the supported diagnosis of upper respiratory infections.

Under certain circumstances, it may be necessary to indicate that a procedure/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.” A different session, procedure or surgery, site or organ system, incision/excision, lesion, or injury must be documented. Only if no more descriptive modifier is available may modifier 59 be used.

An example of the appropriate use of the 59 modifier: A physical therapist performed both CPT code 97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), on one or more regions, each 15 minutes, and 97530 - therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes in the same visit.

Normally these procedures are considered inclusive. If the 59 modifier is appended to either code, they will both be allowed on the claim separately. However, the 59 modifier should only be added if the two procedures are performed in distinctly separate 15-minute intervals. If the therapist performs the procedures simultaneously, then the 59 modifier should not be used.

Public Health Emergency Special Modifiers

How to bill appropriately for services related to COVID-19 is a high priority for most healthcare entities. Described below are examples of the more common modifiers used during the Public Health Emergency (PHE).

As a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act:

1. The “DR” (disaster-related) condition code for institutional billing, i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450.
2. The “CR” (catastrophe/disaster-related) modifier for Part B billing, both institutional and non-institutional, i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format.
3. Modifier “95” (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System) may also be appended but is not required. When billing a telemedicine service (using modifier 95) and another service that requires modifier 25 to be used in addition, the general rule is to report the “payment” modifier before any other descriptive modifier. Since both modifier 25 and 95 can impact payment, list modifier 25 first.

**For details regarding appropriate use of CR and DR Modifiers https://www.cms.gov/files/document/se20011.pdf

References:

How to Use ICD-10-CM, New Lab Testing Codes for Covid-19. AAP News. (March 12, 2020). Retrieved on June 11, 2020 from https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

Modifier 59. (2017). American Medical Association. Retrieved on June 11, 2020 from https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

Medicare-Fee-for-Service (FFS) Response to Public Health Emergency on the Coronavirus (COVID-19). (June 1, 2020). Centers for Medicare and Medicaid Services. Retrieved on June 11, 2020 from https://www.cms.gov/files/document/se20011.pdf