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Proper Use of Modifiers 24 and 25 in E&M Coding

By Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS

The Centers for Medicare & Medicaid Services recently issued new guidelines for the appropriate use of modifiers 24 and 25 in evaluation and management (E&M) coding. Understanding the global period for procedures is a key element in assigning modifiers 24 and 25. Global periods are typically zero, 10, or 90 days after the procedure and may include additional preoperative days.

Proper Use of Modifier 24
Use modifier 24 with the appropriate level of E&M service in the following instances:

• an unrelated E&M service is performed beginning the day after the procedure, by the same physician, during the 10- or 90-day postoperative period;
• documentation indicates the service was exclusively for treatment of the underlying condition and not for postoperative care;
• the same physician is managing immunosuppressant therapy during the postoperative period of a transplant;
• the same physician is managing chemotherapy during the postoperative period of a procedure;
• unrelated critical care is performed by the same physician during the postoperative period; and
• the same diagnosis as the original procedure could be used for the new E&M service if the problem occurs at a different anatomical site.

Do not use modifier 24 under the following conditions:

• the E&M service is for a surgical complication or infection (included in the surgery package);
• the service is for removal of sutures or other wound treatment (included in the surgery package);
• the surgeon admits a patient to a skilled nursing facility for a condition related to the surgery;
• the medical record documentation clearly indicates the E&M service is related to the surgery;
• the service occurs outside of the post-op period for the procedure;
• services are rendered on the same day as the procedure; and
• reporting exams are performed for routine postoperative care.

Following are two scenarios showing use of modifier 24.

Appropriate Use of Modifier 24
A 4-year-old patient is seen in the physician’s office with a 2.5-cm laceration to the right anterior side of the wrist, on which an intermediate layered closure was performed five days ago (CPT code 12031). The patient presents to the physician’s office today complaining of bilateral ear pain. The patient’s mother states he was up all night crying. The physician performs an expanded problem-focused history and examination. The final diagnosis is bilateral otitis media. The provider prescribes amoxicillin and instructs the mother to bring the patient back in seven days to recheck his ears.

The coder correctly assigns the following CPT code to this scenario: 99213-24 Office Outpatient Visit, established patient, expanded problem-focused history; expanded problem-focused physical; medical decision making of low complexity.

Modifier 24 Should Not Be Used
A 4-year-old patient was seen in the physician’s office five days ago with a 2.5-cm laceration to the right anterior side of the wrist, on which an intermediate layered closure was performed (CPT code 12031). The same patient now presents with redness, swelling, and drainage to the sutured area. The final diagnosis was infected laceration.

The coder correctly assigns the following CPT code to this scenario: 99024 Postoperative Follow-Up Visit, Included Surgical Package, E&M Performed. The modifier is not used because all services are included under the code assigned.

Appropriate Use of Modifier 25
Modifier 25 is used to report surgical procedures, labs, X-rays, and supply codes that the physician documents as a separately identified E&M service performed on the same day as another procedure. The E&M service may be prompted by the symptom or condition for which the procedure and/or service was provided. In a situation where a patient presents to the office and a procedure was not anticipated, the E&M can be assigned with the modifier 25.

Examples of Proper Use of Modifier 25

Scenario #1
A patient presents to the emergency department with a chief complaint of lower back pain with sharp pains shooting down both legs. The patient is evaluated and given an intramuscular (IM) injection of Toradol to treat the pain. The patient visit is assigned a level 3 facility E&M level and coded 96372 for the IM injection. No modifier 25 is appended to the E&M level because the status indicator is N (packaged service). The status indicator would need to be S, T, or Q1–Q3 to assign modifier 25.

Scenario #2
A 4-year-old established patient presents to his family practice physician’s office with a 2.5-cm laceration to the right anterior side of the wrist. The laceration is closed by the physician with 2-0 Vicryl. During the visit, the patient’s mother asks the physician about her child’s asthma. The physician decides to adjust the patient’s asthmatic medication and performs an expanded problem-focused physical.

The coder should assign the following CPT codes for this scenario:

• 12001 Simple Repair, Superficial Wounds, Scalp/Neck/Axillae/Genitalia/Trunk/Extremities; 2.5 cm.
• 99213-25 Office Outpatient Visit, established patient, expanded problem focused history; expanded problem focused physical; medical decision making of low complexity.

Conclusion
Use of the modifiers 24 and 25 in E&M coding may seem confusing, but the guidelines above should help. When you clearly understand the global period for procedures, you will have a much easier time knowing when to assign modifier 24 and 25.

— Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS, is the director of coding quality and professional development at TrustHCS.