Pulmonology Coding Alert

Question: I have two questions regarding modifier 21. Can we report it in the office setting, and can we use it on any E/M code?

Montana Subscriber

Answer: CPT designed modifier 21 (Prolonged evaluation and management services) for use when "face- to-face" time with a patient is greater than typically required for the E/M. You can report modifier 21 for office encounters -- when the encounter meets the modifier's other guidelines.

Modifier 21 rules: Use modifier 21 only on E/M codes, not procedure codes. Also, you can only append modifier 21 to the highest-level service within a given E/M category (with the exception of critical care services).

For example, in the "Office or Other Outpatient Services" E/M section of CPT 2008, the only codes that allow for modifier 21 use are 99205 (Office or other outpatient visit for the E/M of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity) and 99215 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity).

Be aware: Modifier 21 use is quite uncommon, and Medicare has pretty strict rules governing its use. Before using modifier 21, be sure to check with your payer to see if the modifier fits your coding situation.