Can you use modifier 24 and 25 at the same time?

Yes, you can use modifier 24 and modifier 25 at the same time, meaning they can both appear on the same claim for services rendered to the same patient on the same date of service. In specific scenarios, a single evaluation and management (E/M) service may even require both modifiers to accurately reflect the service provided.

Understanding Modifiers 24 and 25

To fully grasp why these modifiers can be used concurrently, it's essential to understand their individual purposes:

Modifier 24: Unrelated E/M Service During a Postoperative Period

Modifier 24 signifies an evaluation and management (E/M) service performed by the same physician or other qualified healthcare professional during a global postoperative period that is unrelated to the original surgical procedure.

• Purpose: It allows for separate payment of an E/M service that falls within the global period of a previous surgery but addresses a completely different, unrelated medical condition.
• Example: A patient has cataract surgery. During the 90-day global period, they develop acute conjunctivitis, and the same ophthalmologist treats this new, unrelated condition. The E/M service for the conjunctivitis would be reported with modifier 24.

Modifier 25: Significant, Separately Identifiable E/M Service

Modifier 25 indicates a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified healthcare professional on the same day a procedure or other service is performed.

• Purpose: It unbundles an E/M service from a minor procedure (which typically includes a bundled E/M component). It signifies that the E/M service was substantial enough to warrant separate billing beyond the usual pre- and post-service work included in the procedure.
• Example: A patient visits a dermatologist for a new rash. During the same visit, the dermatologist also removes a benign lesion. The E/M service for evaluating the rash would be reported with modifier 25 because it was a significant service separate from the lesion removal procedure.

Concurrent Use of Modifiers 24 and 25

The ability to use both modifiers stems from the distinct circumstances they describe. Modifier 24 addresses the global period context, while modifier 25 addresses the presence of another procedure on the same day.

When and How They Can Be Used Together

A common scenario where both modifiers may be necessary is when a patient is in a global postoperative period, and on the same day, the physician performs an E/M service for a condition unrelated to the original surgery, and during that same encounter, a minor procedure is also performed that requires a significant, separately identifiable E/M.

Scenario Breakdown:

1. Global Period Active: The patient is within the postoperative period of a previous surgery.
2. Unrelated E/M: The physician evaluates and manages a new or existing condition that is unrelated to the previous surgery. This E/M service is significant.
3. Same-Day Procedure: On the same day as this unrelated E/M, the physician also performs a minor procedure.
4. Separately Identifiable E/M from Procedure: The E/M service performed for the unrelated condition (from point 2) is also significant and separately identifiable from the minor procedure performed on the same day (from point 3).

In this specific situation, the single E/M code would be appended with both modifier 24 and modifier 25. Modifier 25 is typically listed first when stacked with modifier 24.

Example:

A patient is 45 days post-op from a knee arthroscopy (global period active). They present to the same orthopedic surgeon complaining of a new, acute wrist sprain (unrelated to the knee surgery). The physician conducts a comprehensive E/M for the wrist injury. During the same visit, the physician also performs an injection into a trigger point in the patient's shoulder (a minor procedure). The E/M service for the wrist sprain is clearly unrelated to the knee surgery and is significant and separately identifiable from the shoulder injection.

• E/M Service Code (e.g., 99213) + Modifiers 25, 24
• Shoulder Injection Code (e.g., 20550)

This coding indicates:

• The E/M service (99213) was performed on the same day as a procedure (20550) and was significant and separately identifiable (Modifier 25).
• The E/M service (99213) was also unrelated to the original knee surgery, which is still in its global period (Modifier 24).

Key Considerations

• Documentation is Crucial: Thorough and clear documentation is paramount when using both modifiers. The medical record must clearly support:
  • The medical necessity for the E/M service.
  • That the E/M service was unrelated to the global surgery.
  • That the E/M service was significant and separately identifiable from any other procedure performed on the same day.
  • The distinctness of the E/M service from the minor procedure (e.g., separate diagnoses, different body systems addressed, or a significantly expanded scope of work).
• Medical Necessity: Each component (the E/M service, the global period, and the same-day procedure) must meet its own criteria for medical necessity.
• Payer Guidelines: While generally accepted, always verify specific payer guidelines regarding the stacking of modifiers, as policies can vary.

The table below summarizes the attributes of each modifier and their combined application:

Utilizing both modifiers requires a clear understanding of coding guidelines and meticulous documentation to ensure accurate reimbursement and compliance.