Can You Bill Modifier 24 and 25 Together?

Medical billing uses Current Procedural Terminology (CPT) modifiers to provide additional information about a service or procedure. These two-digit codes clarify the circumstances under which a service was performed, aiding accurate claim submission and reimbursement. Understanding their specific application helps healthcare providers avoid claim denials and ensures appropriate compensation for care.

Modifier 24: Unrelated Evaluation and Management Service in a Postoperative Period

Modifier 24 is used when an Evaluation and Management (E/M) service is provided by the same physician or qualified healthcare professional during a patient’s global surgical period, but for a reason unrelated to the original surgery. The global surgical period includes all typical pre-operative, intra-operative, and post-operative care. This period varies, commonly 0, 10, or 90 days following surgery, depending on procedure complexity. Routine follow-up care related to the surgery is bundled into the surgical fee and is not separately billable.

To use modifier 24, the E/M service must address a new problem distinct from the surgical condition. For instance, if a patient is in a 90-day global period after knee surgery but develops flu symptoms, an E/M visit for the flu is unrelated. The modifier signals to payers that this E/M service is not part of the global package and warrants separate reimbursement.

Thorough documentation is essential to support modifier 24. The medical record must clearly indicate the E/M service was solely for an unrelated condition, not routine postoperative care or surgical complications. Using a distinct diagnosis code for the unrelated E/M service strengthens the claim. Without clear documentation, claims with modifier 24 risk denial, as payers may consider the service included in the surgical payment.

Modifier 25: Significant, Separately Identifiable Evaluation and Management Service

Modifier 25 indicates a “significant, separately identifiable” Evaluation and Management (E/M) service was performed by the same physician or qualified healthcare professional on the same day as a procedure. This modifier is appended to the E/M service code to signify the E/M work went beyond the typical pre-operative and post-operative care associated with the procedure. The E/M service must be distinct enough to stand alone as a billable service.

The definition of “significant” and “separately identifiable” means the E/M service addressed a patient’s condition or complaint requiring additional work beyond what is inherent in the procedure. For example, if a patient presents for a scheduled injection for chronic back pain, and a new, unrelated medical issue requiring comprehensive evaluation is identified and addressed, modifier 25 is appropriate for the E/M service. The E/M service may be prompted by the same symptom or condition as the procedure, but it must involve additional, distinct work.

Accurate documentation is paramount when using modifier 25. The medical record must clearly justify the E/M service was separate and distinct from the procedure performed on the same day. This often means detailing a separate history, examination, and medical decision-making process for the E/M service. Without robust documentation, claims with modifier 25 are prone to scrutiny and denial, as payers look for evidence the E/M service was not merely incidental to the procedure.

Application of Both Modifiers in a Single Patient Encounter

While modifiers 24 and 25 address distinct billing circumstances, it is generally not appropriate to apply them to the same CPT code or service line. Modifier 24 relates an E/M service to a global surgical period, and modifier 25 relates an E/M service to a procedure performed on the same day. However, both modifiers can appear on a single claim for services rendered to the same patient on the same day, provided they are applied to different Evaluation and Management service lines.

Consider a scenario where a patient is within the 90-day global period following major heart surgery. During this period, the patient presents to the same surgeon’s office with severe abdominal pain, unrelated to their heart surgery. The surgeon performs a comprehensive E/M service for the abdominal pain, appropriately billed with modifier 24. During the same visit, the surgeon identifies a minor skin lesion requiring immediate removal, and performs a separately identifiable E/M service related to the lesion prior to removal.

In this scenario, two distinct E/M services occurred during one patient encounter. The E/M for the abdominal pain, unrelated to the heart surgery, would be reported on one service line with modifier 24. The E/M service related to the skin lesion removal, significant and separately identifiable from the procedure performed on the same day, would be reported on a different service line with modifier 25. This ensures appropriate reimbursement for the multiple, distinct services provided.

Comprehensive and distinct medical record documentation is essential to support the use of both modifiers in such an encounter. The documentation for each E/M service must clearly justify its medical necessity and adherence to the specific criteria for modifiers 24 and 25. Clear and detailed notes prevent claim denials and potential audits, demonstrating each service was appropriate and separately billable.