Modifiers

Overview and FAQs

Modifier 59 Overview

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation/management services performed on the same day. Modifier 59 is used to identify separate non-E/M services or procedures not normally reported together.

Modifer 59 should be used only if there isn’t a more descriptive modifier available. It should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same day as a minor procedure, see information below on Modifier 25.

Documentation must support a different:

  • session
  • procedure or surgery
  • site or organ system

Documentation must support a separate:

  • incision or excision
  • lesion
  • injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual

For more information on the proper use of Modifier 59, read the MLN Matters Article.


Modifier 25 Overview

Modifier 25 is used to designate a significant, separate E/M service performed by the same physician or qualified non-physician practitioner (NPP) to the same patient on the same day of a minor procedure or other service.

Medicare payments for medical procedures include payments for certain E/M services that are necessary prior to the performance of a procedure. The Centers for Medicare & Medicaid Services (CMS) does not normally allow additional payments for separate E/M services performed by a provider on the same day as a procedure.

Modifier 25 may be attached to allow additional payment for the separate E/M service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient’s medical record to support the need for Modifier 25 on the claim for these services, even though the documentation is not required to be submitted with the claim.

Modifier 25 Billing Example:

A patient’s primary care physician requests an endocrinologist’s opinion regarding a lump the patient discovered on the right side of her neck. The endocrinologist performs a history, an exam and decides to perform an in-office FNA with imaging guidance.

  • 9924X-25 (Office consultation for a non-Medicare patient); or
  • 9920X (Medicare patient that has not been seen by the endocrinologist or anyone in the practice within the last 3 years); or
  • 9921X (Medicare patient that has been seen by the endocrinologist or anyone in the practice within the last 3 years); with a modifier -25
  • 10022- RT
  • 76942

To obtain a clear understanding of Modifier 25, and any limitations that your insurance carrier may have, it is important to contact each carrier directly for further information.

For more information on the proper use of Modifier 25, read OIG.


Modifier FAQs

What’s the difference between Modifier 76 and 59?

Modifier 76 is used for repeat procedures and Modifier 59 is used for separate and distinct procedures.

Example: I aspirated a nodule on the left and it was inadequate, and I had to aspirate the same nodule again. How do I report this to insurer? A repeat procedure or service by the same physician or other qualified health care professional is reported with Modifier 76. It should not be used on E/M codes or on procedures performed on multiple sites (i.e. 2 separate nodules). Documentation should support medical necessity. This modifier should NOT be used when it is a “protocol” to aspirate the nodule multiple times. Always check individual carriers’ guidelines.

When do I use LT/RT versus Modifier 50?

LT/RT should be used with procedures being performed on one side of the body and is a paired organ (e.g., lungs, kidneys, eyes) or to indicate the location of nodules. Modifier 50 is used when the same procedure is performed on both paired body parts (e.g., bilateral carpal tunnel). It is inappropriate to use Modifier 50 when reporting nodules on the right and left. RT/LT should be used to indicate the location of multiple nodules.