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  • Amy Shupe

Commonly Used Modifiers in the Professional Office Setting

Modifiers play an important role in getting your claims paid. Not using a modifier or using the wrong modifier will get part or your whole claim denied. Which then slows the revenue. Below you will find a list of the most common modifiers used in a professional office setting and when and how you should use them.

 

Modifier 24 - Unrelated Evaluation and Management Service by the Same

Physician During a Postoperative Period

When an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.


Example: Patient comes in to have a wart removed. The same patient comes back 5 days later to be seen for a cold. Add the modifier 24 to your E&M code to avoid a denial during the global period.


Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

The patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided. Different diagnoses are not required.


Example: Patient comes in Dysuria (R30.0), the provider decides to do a urine dip. You would add modifier 25 to the E&M code but can use the same ICD-10 code R30.0 for both line items


Modifier 51 - Multiple Procedures

When multiple procedures, other than E&M services, are performed at the same session by the same provider, the primary procedure or service is reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code(s). Use of the 51 modifier on the code with the lower RVU to ensure maximum reimbursement.


Example: A provider performs an excision of a malignant skin lesion. During the patient’s treatment, a separate skin lesion is found in which the provider also would like to remove. To bill correctly and appropriately the provider would use the following codes

  • 12031 (wound closure)

  • 11600-51 (excision of malignant lesion

  • 11100-51 (biopsy of skin, single lesion)

Many would think the excision should be indicated as the primary procedure since it is the reason the patient was being seen. But with modifier 51 dependent upon procedure cost, one should bill the closure (highest cost) as primary, with the second and subsequent procedures of the excision and biopsy (lower cost) needing modifier 51.


Modifier 59 - Distinct Procedural Service

Service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances. It should be noted that a 59 modifier should not be used to override bundles.

Below are some HCPS modifiers that can be used instead of a 59 to unbundle procedures


Modifier XE- Separate Encounter

A service that is distinct because it occurred during a separate encounter.

Modifier XP- Separate Practicioner

A service that is distinct because it was performed by a different practitioner.

Modifier XS- Separate Structure

A service that is distinct because it was performed on a separate organ/structure.

Modifier XU- Unusual Non-Overlapping Service

The use of a service that is distinct because it does not overlap the usual components of the main service.


Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period

The physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedure.


Example: A provider removes a skin lesion on the patient's scalp (11420). During the post-operative global period, the patient returns to have a skin tag removed from his arm (11200) because the skin tag is not related to the original lesion on the scalp you would bill with the 79 modifier. Note this will restart the global period.


Modifier QW- CLIA waived laboratory test

CLIA waived tests requiring the QW modifier are considered simplified analysis tests. A CLIA waived test still requires the provider to include their CLIA number on the claim




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