EM Coding Alert

Use modifier 27 in hospital outpatient settings only.

Turn to Appendix A in the AMA 2017 CPT^® manual, and you’ll see multiple modifier options, including those you can append to your evaluation and management (E/M) services.

In past issues, we’ve focused on modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). But, we would be remiss not to highlight another equally important modifier — modifier 27 (Multiple outpatient hospital E/M encounters on the same date).

Unpack modifier 27’s rules with our handy guide.

Grasp Modifier 27’s Requirements

When documentation supports that your physician provided a second, subsequent E/M service that was separate and distinct from a previous service in a hospital outpatient setting for the same patient on the same day, you can use modifier 27. Using modifier 27 indicates to your payer that the second visit actually occurred and you didn’t report it as a duplicate in error.

To ensure you use modifier 27 appropriately, make sure you follow these rules:

Rule 1: Use Modifier 27 in Hospital Outpatient Settings

You should never append modifier 27 to services your physician provides in his office. Since the 2017 CPT^® manual lists modifier 27 as an ambulatory surgery center (ASC) hospital outpatient modifier, it is only appropriate to append to subsequent services your physician provides in the hospital outpatient setting.

However, although you use modifier 27 just for hospital outpatient settings, it is not necessarily limited to services within a hospital building, according to Jodi Dibble, CPC, medical record coder II of physician services at the Florida Hospital New Smyrna in New Smyrna Beach, Fla.

“This would include hospital-based emergency rooms, hospital clinics, hospital urgent cares, etc.,” says Dibble.

Rule 2: Append Modifier 27 to Specific Codes

According to CMS Transmittal A-10-80 in CR #1725, modifier 27 is only appropriate for the following codes:

• E/M codes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components …) to 99499 (Unlisted evaluation and management service).
• General ophthalmological codes 92002-92004 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program …) for new patients and 92012-92014 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program …) for established patients
• HCPCS codes G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and G0175 (Scheduled interdisciplinary team conference [minimum of three exclusive of patient care nursing staff] with patient present).

Rule 3: Be Sure Different Physicians Provide the Services

You should use modifier 27 only if different physicians (or other qualified health care provider) perform multiple E/M services for the same patient on the same day.

Different from CMS, the CPT^® 2017 manual explains that, “… modifier [27] is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (eg, hospital emergency department, clinic) see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes.)”

Rule 4: Check That E/M Services Occurred at Same Facility

To correctly use modifier 27, the patient must receive the multiple E/M services in the same hospital or system. For example, you would not append 27 to a second hospital visit if the patient was transferred from one hospital emergency department (ED) to a different hospital as an inpatient in a different network with a separate facility tax ID number.

Apply Your Modifier 27 Skills

To learn how to correctly append modifier 27, look at this example from Thomas Field, CPC, CEMC, healthcare economics consultant at Optum in Hartford, Conn.: A patient sees his primary care physician in a provider-based hospital outpatient department for treatment of an upper respiratory infection. On the same date, the patient sees his cardiologist in another department of the same facility for a 6-month follow-up for atrial fibrillation.

Coding solution: The hospital will submit G0463 (Hospital outpatient clinic visit for assessment and management of a patient) for the primary care visit and G0463-27 for the cardiology visit. Be careful to separate the hospital coding solution from the physician. The professional services, because they are two specialists, would be able to bill their own services without any modifier usage (for the multiple E/Ms).