Modifier 25 and modifier 59: when to use them

Modifier 25 vs modifier 59: the short answer

Modifier 25 is added to an evaluation and management (E/M) code to show that the same provider performed a significant, separately identifiable E/M service on the same day as a procedure or other service. Modifier 59 is added to a procedure code to show that it was a distinct procedural service, separate from another procedure done the same day, for example at a different site, in a different session or for a different problem.

The simple rule of thumb: modifier 25 goes on E/M codes, and modifier 59 goes on procedure codes. Modifier 59 should not be used on an E/M code.

This article is a general guide, not coding or legal advice. Payer policies vary, so always check the current rules of the payer you are billing.

When to use modifier 25

Many procedures already include a basic evaluation. When a provider decides to do a minor procedure, the work of assessing the problem and getting consent is usually considered part of the procedure itself. Modifier 25 is for when the provider did more than that.

Modifier 25 is appropriate when the E/M service goes clearly beyond the usual pre-procedure work. Common examples:

• A patient comes in for a scheduled follow-up of diabetes and high blood pressure, and the provider also removes a skin lesion the patient mentions during the visit.
• A patient is seen for a new injury, and during the same visit the provider also manages a separate chronic condition that needed attention.
• During a preventive visit, the provider addresses a significant new problem that requires its own history, exam and decision making.

A separate diagnosis is not strictly required for modifier 25. What matters is that the documentation shows the E/M work was significant and separately identifiable. In practice, though, a separate diagnosis or problem makes the case much easier to support.

When not to use modifier 25

• When the only evaluation was the decision to perform the procedure and the usual pre-procedure assessment.
• On every visit that includes a procedure, as a default. Payers watch for providers who append modifier 25 to nearly all of their E/M claims.
• On procedure codes. Modifier 25 belongs on the E/M code.

When to use modifier 59

Some procedures are normally considered part of another procedure when both are done on the same day. The National Correct Coding Initiative (NCCI) edits, published by CMS, list these code pairs. When two codes in a pair are billed together, the second one is usually denied as bundled.

Modifier 59 tells the payer that, in this case, the two services really were separate. It is appropriate when the second procedure was:

• Performed at a different anatomic site or organ system.
• Performed in a different session or encounter on the same day.
• Performed through a separate incision or excision.
• Done for a separate lesion or a separate injury.

Modifier 59 is meant to be used only when no more specific modifier describes the situation. If a more descriptive modifier exists, such as a laterality or anatomic modifier, use that instead.

The X modifiers: XE, XS, XP and XU

Because modifier 59 was so widely used, and often misused, CMS introduced four more specific modifiers in 2015 to describe why a service is distinct:

• XE (separate encounter). The service was performed during a separate encounter on the same day.
• XS (separate structure). The service was performed on a separate organ or structure.
• XP (separate practitioner). The service was performed by a different practitioner.
• XU (unusual non-overlapping service). The service does not overlap the usual components of the main service.

Medicare accepts these modifiers and may require them in some situations. Other payers vary: some accept them, some prefer modifier 59 and some have their own rules. Check each payer’s policy, and when an X modifier fits the facts, it is generally the more precise choice.

How NCCI edits work

NCCI procedure-to-procedure edits pair a primary code with a secondary code that is usually included in it. Each pair has a modifier indicator. When the indicator allows it, a modifier such as 59 or an X modifier can bypass the edit if the documentation supports a distinct service. When the indicator does not allow it, no modifier will unbundle the pair.

CMS updates the NCCI edits every quarter, so code pairs that were billable together last year may not be this year. Your billing software or clearinghouse should be using the current edits. Many commercial payers use NCCI edits or their own similar edit sets.

Documentation that supports each modifier

The modifier is only a claim. The medical record has to prove it.

For modifier 25

• A clear history, exam and decision making for the separate problem, documented apart from the procedure note where possible.
• The reason the E/M work was needed beyond the decision to do the procedure.
• The diagnoses addressed during the E/M service.

For modifier 59 or the X modifiers

• The specific site, lesion, session or incision for each procedure.
• Times, where separate sessions are involved.
• Enough detail that a reviewer reading the note can see the services were separate without needing to ask.

Common modifier 25 and 59 mistakes

1. Using modifier 59 to get past every bundling edit. If the services weren’t distinct, the modifier doesn’t make them distinct. This is one of the patterns auditors look for.
2. Putting the modifier on the wrong code. Modifier 25 goes on the E/M code, and modifier 59 goes on the secondary procedure code in the pair.
3. Appending modifier 25 to every procedure visit. A very high modifier 25 rate compared to peers can trigger review.
4. Ignoring more specific modifiers. Using 59 when an X modifier, laterality modifier or other specific modifier applies.
5. Thin documentation. A note that only describes the procedure won’t support a separate E/M service, however much work the provider actually did.
6. Not checking payer policy. Some payers reduce or deny E/M services billed with modifier 25 under their own rules. Know those policies before the claim goes out.

What to do when modifier claims are denied

If a claim with modifier 25 or 59 is denied, read the remittance codes first. A bundling denial usually points to an NCCI or payer edit. Our guide to claim denial codes explains how to read them. If the documentation supports the modifier, appeal with the relevant part of the note attached. If it doesn’t, the fix belongs in documentation and provider education, not in the appeal.

Tracking modifier denials by provider and by code pair often shows a pattern quickly. That pattern is where coding review and training pay off. Our medical coding team reviews modifier use as part of our coding audits.

Check your modifier use with a free audit

Modifier problems usually show up as a steady trickle of bundling denials and reduced E/M payments that nobody has time to trace. Request your free A/R audit and we’ll show you where modifier 25 and 59 denials are coming from in your recent claims. You keep the findings whether or not you work with us.