Modifiers 59, 25 and 91: A Guide for Coders

“If it isn’t coded then it hasn’t been done,” is a proverb that isn’t heard in the healthcare setting frequently enough.

Correctly applying modifiers, though, isn’t always as cut and dry as it seems. Many times providers inappropriately use modifiers, an abuse that inevitably leads to claim denials.

“Modifiers are essential tools in the coding process,” says Laura Reeds, director of coding compliance at IASIS Healthcare in Franklin, Tenn. “They clarify how things should be paid … and further explain or qualify a CPT code.”

CPT modifiers (also referred to as Level I modifiers) are used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Code modifiers help further describe a procedure code without changing its definition.

Let’s take a look at 3 commonly misused modifiers, and how they’ve been applied to different care situations.

Modifier 59
CPT Manual defines modifier 59 as a “Distinct Procedural Service.”

The 59 modifier is considered the most misused modifier by coders. It is normally used to indicate that two or more procedures were performed during the same visit to different sites on the body.

Unfortunately, it is too often applied to prevent a service from being bundled or conjoined with another service on the same claim. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier’s edit system.

59 should also only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes. If there is another modifier that more accurately describes the services being billed, it should be used in place of the 59 modifier.

A dermatologist does a Photo Dynamic Therapy session with a BLU-U machine on the face/scalp of a patient. Following the face/scalp session, the BLU-U was repositioned to treat other extremities.Coding examples:9656796567 – 59The first code is the face/scalp performed on the patient. Then, modifier 59 is added to the second procedure indicating a distinctly different procedure performed on separate extremities. ”

Modifier 25
In Appendix A of the CPT 4 Manual, modifier 25 is defined as follows:

“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.”

This modifier for physicians to indicate that on the day a procedure or service (identified by a CPT code) was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided.

When Not to Use the Modifier 25:

  • Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery.
  • Do not add modifier 25 if there is only an E/M service performed during the office visit and no procedure.
  • 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.

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 the patient needs a cardiovascular stress test that same day.Coding example:99214 – 2593015The physician codes an E/M visit (99214) 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. ”

Modifier 91
Modifier 91 should be used when repeat tests are performed on the same day, by the same provider to obtain reportable test values with separate specimens taken at different times, and only when it is necessary to obtain multiple results in the course of treatment.  When billing for a repeat test, use modifier 91 with the appropriate procedure code.

When not to use modifier 91:

  • Used for a rerun of a laboratory test to confirm results
  • Due to testing problems for the specimen
  • Due to testing problems of the equipment
  • When another procedure code describes a series test
  • When the procedure code describes a series of test
  • For any reason when a normal one-time result is required

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 physicians may use variations in PRA levels due to time of day and patient position to evaluate certain conditions such as hyperaldosteronism they may order a repeat renin in the afternoon with the patient standing upright for a period of time.Coding example:8424484244 – 91Report the second 84244 with modifier -91 to indicate that the lab performed two separate renin assays for the same patient on the same day. ”

If you’d like more information, all modifiers can be found in the CPT (Current Procedural Terminology) and HCPCS (HCFA Common Procedural Coding System) codebooks.

Want to learn new ways to improve your revenue stream? Check out our 7 Best Practices for Accounts Receivable Management whitepaper.