Basics about modifier -27 and 25

Many times, we get multiple visit cases of same day for same patient in Emergency Department. In such scenarios, we have to use modifiers to avoid them as duplicate claims. I have already posted previously how and which modifiers are used in medical coding. We already know the most common modifier used for E&M (Evaluation and Management) is modifier 25 and 27.

Knowledge of Modifiers is important for Clearing CPC exams. However, when there are multiple visits we have to use one more modifier along with E&M level codes 99281-99285. Use of modifiers should be perfect from E&M to Surgery CPT codes.The multiple visits on same day are only being paid when we properly use the modifiers. Therefore, let us checkout the modifiers used with E&M level codes 99281-99285 for Emergency department multiple visits.

Read also: Modifier 76 secret tips

Check for S and T indicators for 25 modifier

The S and T indicators present with any procedure done with E&M level code, helps in adding modifier 25 with 99281-99285 CPT codes. Modifier 25 is appended with E&M codes, only when the same physician performs a separate procedure on the same day. Mostly the X rays, CT without contrast, Labs, IV infusion, injection are the common procedures done with E&M codes. The presence of S & T indicators plays an important role in using modifier 25 with E&M level codes.

Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service)

According to Medicare:

• Modifier 25 is used to facilitate billing of E/M services on the day of a procedure for which separate payment may be made.
• It is used to report a significant, separately identifiable E/M service by the same physician on the day of a procedure.
• The physician may need to indicate that on the day a procedure was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed.
• Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service.
• Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented in the patient’s medical record to support the claim for these services.
• This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service.
• Modifier 25 should always be attached to the E/M code. If provided with a preventive medicine visit, it should be attached to the established office E/M code (99211–99215).

Read also: Modifiers used with PET CT scan CPT code

Use 27 modifier for multiple visits

There can be multiple visits by the same patient to ED department. In such scenarios, we have to use modifier 27 with the second visit. This modifier is used only for outpatient hospital settings like Emergency department, clinic etc. We can use modifier 25 and 27 together, so do not get confuse with both these modifier. Both modifiers are defined separately and so use them correctly with E&M codes.

Use modifier -27 for multiple outpatient hospital evaluation and management (E/M) encounters on the same date. Use this modifier when a patient receives multiple E/M services performed by the same or different physicians in multiple outpatient hospital settings (e.g., emergency department, clinic, etc.)

Coding examples for Modifier 25

 1. A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed that day by the same physician.

Coding Rationale for above case; The physician codes an E/M visit (99201 – 99215) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure.

CPT code: 99214 -25, 93015 

2. A 15-month-old girl presents with a fever (103°F) and mom states the girl has been tugging at her right ear for 2 days. A detailed history is obtained and a problem-focused examination is completed. When the doctor examines the ears he notices that the middle ear is very inflamed (pus is present) and the child is extremely uncomfortable. The doctor decides to administer ceftriaxone sodium to the child. The final diagnosis is acute suppurative otitis media without rupture of eardrum.

CPT code: 99213-25, 90777

Do not Use Modifier 25 in below scenarios

1. Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery.
2. Do not append modifier 25 if there is only an E/M service performed during the office visit (no procedure done).
3. Do not use a modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed.
4. Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have “inherent” E/M service included. See example #2.
5. Patient came in for a scheduled procedure only

When to use Modifier 27

Modifier 27 is reported for multiple outpatient hospital evaluation and management (E/M) services on the same date.Hospitals may append modifier 27 to the range of E/M service codes listed below:

Condition code ‘G0’ while using Modifier 27

The condition code G0 is used only for Hospital Outpatient Prospective Payment System (OPPS). The Condition code G0 indicates the multiple visits on same day as distinct and independent for each other and hence qualifies for the separate reimbursement for each visit. Modifier 27 will be use appropriately with E&M codes for multiple visits. 

Hope, now medical coders will be able to code the live or example charts of E&M facility with correct use of these modifiers. Do share you thoughts about -25 and -27 modifier in the comment section below.