Appropriate use of modifiers is one of the most common areas of confusion in medical billing. That confusion often leads to unnecessary denials, delayed payment and even payor audits. Because humans are fallible, every physician practice should make sure that it has access to a dynamic, custom25izable rules engine that can help flag errors before billing and suggest appropriate alternatives. CPT code modifiers in medical billing (also called Level I modifiers) provide additional information or adjust care descriptions to provide extra details about a procedure or service provided by a physician. Code modifiers help further describe the circumstances of the procedure for medical billing purposes without changing its definition. We have published content regarding Modifier 59 and the recent changes in the structure and appropriate use of this modifier in our MDeverywhere Insights Blog. So now we will take a look at 2 other commonly misused modifiers, 25 and 91.
In Appendix A of the CPT 4 Manual Modifier 25 is defined by: “Modifier 25 is a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.” Physicians can use this modifier to show that on the day they performed a procedure or service (identified by a CPT code), the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided. Modifier 25 should not be used when:
- Billing for services performed during a postoperative period if related to the previous surgery.
- If there is only an E/M service performed during the office visit.
You should also not append modifier 25 to an E/M service when performing a minimal procedure on the same day unless you can support the level of service as significant, separately identifiable. Example of Modifier 25 Situation: A cardiologist sees a patient complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. During the course of the office visit, the physician determines the patient needs a cardiovascular stress test that same day. Coding example:
The physician codes an E/M visit (99214) and he or she also codes for the cardiovascular stress test (93015). They then add modifier 25 to the E/M visit to show that there was a separately identifiable E/M service on the same day of a procedure.
Modifier 91 is used when the same provider performs repeat tests on the same day. In this scenario, the clinician obtains reportable test values with separate specimens taken at different times. This generally is only when it is necessary to get multiple results in the course of treatment. When billing for a repeat test, consider modifier 91 with the appropriate procedure code. When not to use modifier 91:
- Rerun of a laboratory test to confirm results
- Rerun due to testing problems with the specimen
- Rerun due to testing problems with the equipment
- When the procedure code describes a series of tests
- For any reason when a normal, one-time result is required
Example of Modifier 91 Situation: A patient with high blood pressure who has been on a low-salt diet may receive a plasma renin activity (PRA) test (84244 Renin) in the morning in the supine position. Because the physician may require variations in PRA levels due to time of day and patient position to evaluate certain conditions such as hyperaldosteronism, he or she may order a repeat renin in the afternoon with the patient standing upright for a period of time. Coding example:
Report the second 84244 with modifier -91 to show that the lab performed two separate renin assays for the same patient on the same day. Understanding the appropriate application of these modifiers is a critical component to an effective revenue cycle process. Having all the right tools and systems in place to ensure the appropriate use of modifiers can significantly reduce denials and increase patient collections. State-of-the-art revenue cycle systems like MDeverywhere's Practice 1st should include customizable rules engines to help your team navigate these complex coding rules. For more information, you can review the CPT manual.