Modifiers can generally be grouped by function or category. Some modifiers are used for tracking or informational purposes only, while others affect measurement of time, effort, or result in altered reimbursement. Some have multiple functions. An example is modifier “AI”; this is a level II HCPCS modifier which indicates the principal or admitting physician. This helps to track providers but also is used for payment of certain consult codes.
In a previous segment, Modifiers Part I, we covered a general overview. In this segment we will review modifiers for E&M services.
Modifier 24 is used when an unrelated E&M is billed by the same physician during the post-operative period. This involves care which is unrelated to typical post-operative recovery and treatment during the global period of a procedure. The global surgical period is assumed to include the regular course of post-op care, so therefore the separate E&M service must be untypical but not necessarily unrelated. Note however, that Medicare takes a different view of this modifier than CPT. CPT says an unrelated E&M could also qualify as “significant complications” of the initial procedure but which are not typical. Medicare allows use of modifier 24 only when the E&M is entirely unrelated to the initial global surgical package. Medicare’s definition of a global package is inclusive of all post-operative visits and all additional care (which don’t result in further OR time). Additional surgical service may be paid for, but not the E&M.
Modifier 25 is used when a significant separately-identifiable E&M service is provided by the same physician on the day of a procedure. There are two key points included. It needs to be separate from the procedure, and it needs to be significant. “Separate” indicates sufficient differentiation to substantiate a new problem focused E&M service, as well as separate documentation of the service. This would involve more than just a cursory review of the patient.
Additional E&M modifiers will be covered in Part III.