Medical Billing Forum

Coding => Coding => Topic started by: MJ on November 25, 2008, 01:22:11 PM

Title: modifiers
Post by: MJ on November 25, 2008, 01:22:11 PM
Can you give me a sort of cheat sheet or hints for how to use Modifier 25 & 59.  I get confused because sometimes to me, they mean the same thing.  Thank you
Title: Re: modifiers
Post by: Michele on November 25, 2008, 08:38:48 PM
   The following is from Blue Cross Blue Shield and it explains the 2 modifiers.  They are similar but should be used for different things.  For example, I use the 25 modifier for one of my doctors because he will do an office visit (E&M code) in addition to osteopathic manipulation on the same visit.  The E&M is separate from the osteopathic manipulation so I attach the 25 modifier and he receives payment for both codes.  I use the 59 modifier for PT codes when I bill 97110 along with 97530 or 97140.  I attach the 59 modifier to the 97530 & 97140 and again all codes are allowed.  Without the 59 modifier the 97530 & 97140 are bundled into the 97110.  I hope this helps.


Modifier 25 
Definition: Significant and Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.

Modifier 25 is used to describe separate, distinctly identifiable services from other services or procedures rendered during the same visit. Always attach the modifier to the evaluation and management code.

Some examples of separate and distinctly identifiable services are:

    * Initial hospital visit, initial inpatient consultation or hospital discharge and an inpatient dialysis service. Modifier 25 would be appropriate on the E&M code.
    * Unscheduled E&M service performed the same day as a preventive exam-when the service is in addition to the preventive care.

Do not use modifier 25:

    * On surgical codes.
    * On services that resulted in the decision to perform surgery.

Modifier 59       

      Definition: Distinct Procedural Service

      Modifier 59 is used to clearly designate when distinct, independent and separate multiple procedures are provided. The procedure must not be a component of another procedure.

      Examples of when to use modifier 59:
          o Different procedures or surgeries
          o Surgery on different sites or organ systems
          o Separate incision/excision
          o Separate lesions
          o Treatment to separate injuries
            Documentation may be required to support the use of modifier 59.

      Do not use modifier 59 on all procedures on the claim. This will negate the purpose of the modifier.
Title: Re: modifiers
Post by: Aasha on December 18, 2008, 01:00:46 AM
Recently I started billing for pediatric office. Could you please help me how to use the modifiers and what type of modifiers are most commonly used for pediatric billing.

Title: Re: modifiers
Post by: Michele on December 18, 2008, 06:46:20 AM
There aren't a lot of modifiers you will need for pediatric billing.  You may find the need for the 25 modifier.  That would be used if for example a patient came in for a well child check and also had a medical problem that the dr attends to, such as upper respiratory infection.  If the doctor wants to code it out separately you would bill the well child code and an E&M (like 99213) for the upper respiratory infection, and you would put the 25 modifier on the E&M line.

You may also need to use the 50 for bilateral, or RT LT to indicate which side.  The only other one I can think of is 59 to indicate distinct separate procedure if multiple services were performed that may be bundled together.

More detailed descriptions of the 25 & 59 modifier are above.