Medicare Compliance & Reimbursement

If you’re often mixing up your E/M modifiers, then clip this article and post it near your desk. You’ll be sure to apply the appropriate modifier every time.

Pick Modifier 24 for Post-Op Cases

When you report modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), the E/M service must meet these criteria:

• The E/M service occurs during the postoperative period of another procedure.
• The current E/M service is unrelated to the previous procedure.
• The same physician (or tax ID or same group and specialty) who performed the previous procedure provides the E/M.

Ensure Separately Identifiable Procedure for Modifier 25

Appending modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) means the E/M service must meet these requirements:

• The E/M is significant and separately identifiable from any "inherent" E/M component included with other services/procedures you report on the same day. The office visit is not merely preoperative in nature or an integral part of the procedure.
• The E/M may be related or unrelated to other procedures/services you report on the same day.
• The same physician bills the E/M and other procedures/services on the same day.
• You must maintain documentation proving the medically necessary and separately identifiable nature of the E/M service, even though you needn’t submit that documentation with the claim.

E/M Related to Surgical Decision? Use Mod 57

To properly append modifier 57 (Decision for surgery), remember these points:

• The E/M service must occur the day of or the day before a major surgical procedure (a procedure with a 90-day global period).
• The E/M service must prompt the surgical procedure that follows.
• The E/M service must be related to the procedure that follows.
• The same physician (or tax ID) provides the E/M service and the surgical procedure.