Many physician practices do not use current procedure terminology modifiers, or they use them incorrectly. Generally, this is a result of not having a clear understanding of the modifiers and their importance in the reimbursement cycle.  A savvy practice not only knows about modifiers, they also know how, when, where and why to attach them to codes.

Modifiers are meant to change the meaning of a CPT code to give it more accuracy and increase or decrease the reimbursement. The order that the modifiers are listed on a claim can cause additional reimbursement or can lead to claim denials. 

Modifiers fall into two categories:

1. Current procedure terminology (CPT): consist of two digits, and both are numeric. CPT modifiers affect reimbursement.

2. Healthcare Common Procedure Coding System (HCPCS): consist of two digits, but they can be either two alphas or an alpha and a numeric digit. HCPCS modifiers generally are informational.

Evaluation and Management

The following CPT modifiers are only used on E/M codes. They never get appended to a procedure or surgical code. 

24 - Unrelated  evaluation and management service by the same physician during a postoperative period.

25 - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.       

57 - Decision for surgery

Modifier 57 probably has the most confusion around its use. This modifier is only used when the decision to have surgery occurs within 24 hours of the surgery, and the surgery is a major surgery with a 90 day post-operative period. If a surgery is planned two weeks in advance, there is no modifier that is attached to the E/M code.

Most people believe that this modifier is used at the visit when it is decided to do surgery. This is only correct if the surgery is going to occur within 24 hours, as you need to break the E/M visit away from the preoperative exam portion of the surgical code.

Two common examples of the use of this modifier is a patient that presents with a retinal detach, or a patient that presents with a perforated cornea.  Both of these are emergencies that need to be repaired fairly quickly to ensure a good outcome.  

Modifier 24 is used when a patient comes into the office to be seen for an unrelated problem during the global period for another surgery. This could be the patient that has glaucoma and is    coming in following cataract surgery to have their glaucoma checked. The addition of this modifier tells the insurance that this is not a postoperative visit, but an unrelated issue and deserves to be reimbursed.

Modifier 25 is used when a patient presents to the office with a problem, and the decision is made to do the procedure that day. This modifier is attached to the procedural code(s) that have a zero or 10-day postoperative period. This modifier is never attached with a procedure that has a 90 day postoperative period.  If you have a patient that comes in with a problem that needs a minor procedure during the postoperative period of any surgery, the order of the modifiers will make the difference in whether or not reimbursement is made.

For a problem that requires a procedure on that day, it is important that the chart notes are distinct from the procedure notes. Do your chart notes, recommend the procedure, and sign off on the chart. Then open a new chart note and indicate the need for the procedure, and document the procedure that was done and sign off on it. If this procedure is done during a postoperative period, you will need to list your modifiers in the order of 24, 25. The first modifier (24) breaks the bundling issue for the E/M code, while the second modifier (25) breaks the bundling issue between the visits that day and the procedure.