Can Modifier 24 and 25 Be Used Together?

Medical coding modifiers are alphanumeric codes that provide additional details about a medical procedure or service without changing its fundamental definition. These two-digit codes, appended to Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, enhance billing specificity. Modifiers are essential for accurate claim submission and proper reimbursement, clarifying unique circumstances of patient encounters. Their precise application helps healthcare providers receive appropriate payment, minimizing claim denials.

Understanding Modifier 24

Modifier 24, “Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period,” indicates an Evaluation and Management (E/M) service provided during a global surgical period is unrelated to the original surgery. This modifier applies when the same physician performs an E/M service for a new or different problem, distinct from the condition for which the surgery was performed.

A global surgical period encompasses the timeframe when follow-up care is considered part of the surgical fee. This period typically varies (0, 10, or 90 days) and includes routine preoperative, intraoperative, and postoperative services. For example, a major surgery often has a 90-day global period, while minor procedures might have 0 or 10 days. Services related to surgical complications or routine post-operative care, such as suture removal or wound checks, are generally included in this global payment and should not be billed with modifier 24.

An appropriate use of modifier 24 occurs if a patient undergoes knee surgery with a 90-day global period and, 30 days later, visits the same orthopedic surgeon for an unrelated issue like flu symptoms or new shoulder pain. In this scenario, the E/M service for the flu or shoulder pain, distinct from the knee surgery recovery, would be reported with modifier 24.

Understanding Modifier 25

Modifier 25, “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of a Procedure or Other Service,” reports an E/M service distinct and significant enough to warrant separate billing when performed on the same day as a procedure by the same provider. This modifier applies only to E/M services, not to procedures.

A “significant, separately identifiable” E/M service means the work performed goes above and beyond the typical evaluation and management associated with the procedure. For example, if a patient presents for a scheduled injection for chronic back pain, and during the visit, also discusses new, significant mental health concerns requiring separate counseling, the counseling E/M service would be reported with modifier 25.

Another instance for modifier 25 use occurs when a patient presents with a laceration. Before repairing it, the physician performs a comprehensive E/M to assess for neurological damage. The E/M service in this case is significant and distinct from the laceration repair itself, even if both services share the same diagnosis. However, if the sole purpose of the visit is for a minor procedure with no other significant problem addressed, modifier 25 should not be used.

Applying Modifier 24 and Modifier 25 Together

The simultaneous application of Modifier 24 and Modifier 25 on the same claim for the same patient encounter is possible, though rare. This combined use is appropriate when an Evaluation and Management (E/M) service, unrelated to a prior surgery and occurring within its global postoperative period, is performed on the same day as a new, distinct procedure by the same physician. The E/M service must also be significant and separately identifiable from this new procedure.

Consider a scenario where a patient had major surgery with a 90-day global period. If, within this period, the patient returns to the same physician for an E/M service addressing a completely unrelated medical issue, modifier 24 would be appended to that E/M service. If during that same visit, the physician identifies a new, distinct problem related to the unrelated E/M and performs a minor surgical procedure for it, modifier 25 would then be additionally appended to the E/M service. This indicates the E/M service was both unrelated to the original surgery (Modifier 24) and significant and separate from the new procedure performed on the same day (Modifier 25).

For example, a patient recovering from a hip replacement (90-day global period) develops a new, unrelated skin lesion on their arm and visits the same surgeon. The E/M service to evaluate this lesion would use modifier 24. If, during that same visit, the surgeon performs an immediate biopsy or removal of the lesion, the E/M service leading to that new procedure would also require modifier 25. The E/M service is therefore modified by both 24 and 25 because it is unrelated to the hip surgery and separately identifiable from the new lesion procedure.

When both modifiers are used, Modifier 24 is typically listed first, followed by Modifier 25, reflecting the sequence of coding logic.

Documentation Requirements

Thorough and accurate medical record documentation is paramount when utilizing Modifier 24 and Modifier 25, especially in combination. For modifier 24, documentation must clearly establish the Evaluation and Management (E/M) service is unrelated to the original surgical procedure. This includes a clear, distinct diagnosis code for the unrelated condition and detailed notes explaining why the visit falls outside the scope of normal postoperative care. The clinical context must justify the separate E/M.

For modifier 25, documentation must demonstrate the E/M service is significant and separately identifiable from any procedure performed on the same day. This means the E/M work must be above and beyond usual pre- and post-procedure activities. Ideally, documentation for the E/M service should be physically separated or clearly distinct from procedure notes within the patient’s medical record, supporting the E/M as a standalone, billable service.

When both modifiers 24 and 25 are applied, documentation must simultaneously support both criteria. It needs to show the E/M service is unrelated to the initial global surgery and also significant and separately identifiable from any new procedure performed during that same encounter. Inadequate documentation is a leading cause of claim denials, emphasizing the importance of detailed, precise, and supportive entries in the patient’s chart for all reported services.