Written by Brooke Haycraft, CEMC, CFPC, CPC-H, CPC
CPT (Current Procedural Terminology) defines a modifier as, “a combination of two characters letters or alphanumeric codes that are meant to convey additional information regarding the procedure or services offered by the physician or hospital.”
The use of modifiers plays a vital part in coding and ‘paint a picture’ of services provided in a healthcare setting. Appending the appropriate modifier also plays an important role of avoiding fraud and abuse, and adhearing to compliance regulations issued by state and federal agencies.
Applying modifiers isn’t always as easy as it seems and inevitably could lead to claim denials or audits if not used properly. Let’s briefly take a look at a few modifiers that are bound to turn up when coding for E/M (evaluation and management) services. Learning to decipher, ‘fact vs. fiction’ when using modifiers 24, 27, & 57 in your practice will help reduce the risk of lost revenue and improve coding compliance.
Modifier 24
Modifier 24 is used when a patient is seen by a provider for an unrelated E/M service by the same physician (physicians in the same group practice who are in the same specialty, per CMS guidelines) during a postoperative period.
Fact or Fiction?
1. Modifier 24 should be appended to an office visit when a patient is seen for a post-surgical complication or infection.
• Answer: FICTION. Any treatment or services related to the global (10 or 90 day) procedure are considered part of the surgical package.
2. Modifier 24 should be added to an x-ray procedure that is performed for an unrelated medical condition within the global surgical period.
• Answer: FICTION. This modifier should only be submitted with E/M and eye exam codes.
3. Modifier 24 is appropriate to add to service provided by the physician on the same date of service as the global surgery.
• Answer: FICTION. Modifier 24 cannot be utilized the same day as the procedure or outside of the post-operative.
Modifier 27
Modifier 27 is utilized when multiple outpatient hospital E/M encounters on the same date occur.
Fact or Fiction?
1. Modifier 27 should be appended to BOTH E/M codes when more than one E/M service is provided that same day in the same or different hospital outpatient setting.
• Answer: FICTION. Modifier 27 should be added to the second subsequent E/M visit for date of service in question.
2. The following example is a good illustration of when modifier 27 should be utilized—
A 50-year-old-male lacerated his knee in a chainsaw injury and presented to the local emergency department for treatment. The patient is evaluated and sent to the hospital clinic to see a cosmetic surgeon who specializes in these injuries on the same day.
• Answer: FACT. The patient was seen in two different facilities on the same date of service—both the hospital clinic and emergency department. Without appending the modifier 27 to the hospital clinic claim, a third-party payor may view this as a duplicate service and deny the claim as such.
Modifier 57
Modifier 57 indicates an E/M service resulted in the initial decision to perform surgery either the day before a major surgery (90 day global) or the day of a major surgery.
Fact or Fiction?
1. Modifier 57 can and should be appended to new patient visits.
• Answer: FICTION. CMS guidelines state that modifier 57 is appended to E/M services that result in the initial decision to perform the surgery and only if this decision was made on the day of or day prior to the major surgical procedure. New patients are excluded from the global surgery package. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
2. Modifier 57 should be attached to both the E/M and surgical procedure.
• Answer: FICTION. Modifier 57 is only to be utilized on E/M services.
3. Modifier 57 is appropriate for E/M services performed on the same day as a minor surgery (10 day global period).
• Answer: FICTION. When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not separately billable above/beyond the procedure performed.
FACT: Modifiers play a critical role in increasing your practice’s revenue. Appending the appropriate modifiers to E/M codes as indicated above in accordance with CPT and CMS guidelines will assist in getting your claim reimbursed the first time, every time.