Coding tips: Modifiers -25, -26, and -59

When used appropriately, modifiers help physicians collect revenue to which they’re entitled because they convey to payers that the claim should bypass billing edits that are designed to prevent improper payments. However, when practices use these modifiers to bypass edits inappropriately, they could be at risk for recoupments resulting from post-payment audits, says Angie Clements, CPC, physician coding auditor at MedKoder LLC in Mandeville, La.

It all comes down to documentation, says Clements. “Documentation has to support everything you do. Payers are looking at the documentation to support everything they pay,” she says.

Here are some do’s and don’ts when applying these three common modifiers:

Modifier -25

DO apply it when the E/M service goes above and beyond the usual pre- and post-operative work associated with a procedure that has a global fee period. Documentation must clearly explain why the additional E/M service was necessary and why it went above and beyond what’s typically required for the procedure, says Clements.

For example, a patient falls and has a laceration to the forehead that’s deep enough to require sutures. In addition to the laceration repair, the physician performs an exam and neurological assessment to rule out a concussion and orders additional testing. The E/M code for the office visit may be separately reportable using modifier -25 provided all documentation requirements are met, says Clements.

DON’T apply it automatically just because a non-physician provider performs part of the treatment. As always, documentation must justify why the E/M service is separately reportable, says Clements.

DON’T apply it when a patient presents for a scheduled procedure. For example, a physician performs an E/M service and asks the patient to come back in a few days for an injection if symptoms worsen. If the patient returns, the physician should only bill the CPT code for the injection-not an additional E/M code with modifier -25, says Clements.

Modifier -26

DO apply it when a physician performs the professional component only. For example, CPT code 71045 denotes a single-view chest X-ray. If a physician performs the professional component only, they should report this code with modifier -26.

DON’T apply it when there is a more specific code. For example, CPT code 93000 denotes a routine electrocardiogram (ECG) with at least 12 leads, including the tracing, interpretation, and report. If a physician performs only the interpretation and report (without the tracing), they should report CPT code 93010-not 93000 with modifier -26.

DON’T apply it when another physician already interpreted the test. Physicians can count their own interpretation toward their medical decision-making but not bill separately for the professional component of the test, says Clements.

Modifier -59

DO apply it as a last resort. Consider these other options first: -RT (right), -LT (left), or -50 (bilateral procedure). Payers may also accept modifiers -XE (separate encounter), -XS (separate organ or structure), -XU (unusual non-overlapping service), or -XP (separate practitioner). For example, a physician performs an injection in the right and left knees. Report CPT code 20610 with modifier -50 not -59.

DO apply it when there’s a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury. For example, a physician trims a callus and trims a toenail on the same toe. The toenail, bed, and surrounding tissues are considered the same anatomical site, says Clements.

DON’T apply it if National Correct Coding Initiative (NCCI) edits prohibit doing so. For example, physicians shouldn’t report a biopsy and excision of the same lesion using modifier -59. They should only report the removal, says Clements. An exception to this is when a physician biopsies the lesion, waits for the pathology results, and then excises the lesion during the same session. In this case, they can report both procedures using modifier -59. If there isn’t any documentation to support the decision to excise the lesion after pathology results were obtained, payers may recoup reimbursement during a post-payment audit, she adds.