Orthopedic Coding Alert

Learn the criteria you have to meet.

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. You can think of significant as defined as worth more relative value units (RVUs) than the other code. For instance, if you do an injection, you can only report the E/M code if the E/M service is worth more RVUs than the injection (which is usually at least a Level 3, many times a level 4).
• 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.