Can You Use Modifier 24 and 25 Together?

Medical billing and coding rely on a system of modifiers to accurately describe the services provided to patients. These modifiers offer additional information about a procedure or service, clarifying circumstances that might affect reimbursement. Among the numerous modifiers, Modifier 24 and Modifier 25 are frequently used, each serving a distinct purpose in communicating the complexities of patient encounters.

Purpose of Modifier 24

Modifier 24, formally defined as “Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period,” indicates that an Evaluation and Management (E/M) service performed during a surgical global period was unrelated to the original surgery. A global surgical period is a defined timeframe following a surgical procedure during which all routine, related care is bundled into a single payment for the surgery. This bundled payment, known as the global surgical package, includes preoperative, intraoperative, and postoperative care.

The global period can vary based on the procedure’s complexity. Minor procedures might have a 0-day or a 10-day global period, while major surgeries have a 90-day global period. Services included in the global fee are immediate postoperative care, routine follow-up visits, and management of complications, unless they require a return to the operating room. The purpose of the global period is to simplify billing and prevent separate charges for services integral to the surgery’s recovery.

Modifier 24 is applied when the same physician or group provides an E/M service during this global period for a condition unrelated to the initial surgery. For instance, if a patient undergoes knee surgery and, within the 90-day global period, develops an unrelated skin infection or an exacerbation of a chronic condition like hypertension, the E/M service to address these new issues would appropriately carry Modifier 24. This modifier signals to the payer that the E/M service should be reimbursed separately because it addresses a distinct medical problem. Modifier 24 is only appended to E/M codes and not to surgical procedure codes or for routine follow-up care related to the surgery.

Purpose of Modifier 25

Modifier 25, defined as “Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service,” is used when a distinct E/M service is provided on the same day as a procedure. This modifier indicates that the E/M service was significant and separate from the usual pre- or post-procedure care associated with the procedure performed. Without Modifier 25, payers often bundle the E/M service into the payment for the procedure, assuming it was part of the standard procedural work.

For example, if a patient visits a physician for a skin tag removal (a procedure), but during the same visit, the physician also performs a comprehensive E/M service for a new, unrelated complaint like severe abdominal pain, Modifier 25 would be appended to the E/M code. The E/M service must be clearly documented as distinct and significant enough to warrant separate billing. This modifier is frequently used with minor procedures that have 0- or 10-day global periods.

The key is that the E/M service addresses a significant, separately identifiable problem or condition, even if it relates to the same symptom that prompted the procedure. For instance, if a patient presents with a head laceration and, before repair, the physician performs an E/M to assess for neurological damage, Modifier 25 would be used with the E/M service.

Conditions for Combined Use

The combined use of Modifier 24 and Modifier 25 is possible, though it represents a specific scenario in medical billing. This combination becomes appropriate when an E/M service, unrelated to a patient’s prior surgery and occurring within that surgery’s global period, is performed on the same day as another separately identifiable procedure or service. The E/M service must be unrelated to the initial surgery, occur during its global period, and be provided on the same day as a different, distinct procedure.

Consider a patient who is 30 days into the 90-day global period following a major knee replacement surgery. They come in for a follow-up for the knee, which is included in the global package. However, during this visit, they also present with acute chest pain, a condition unrelated to their knee surgery. The physician performs an E/M service to evaluate this new chest pain. Simultaneously, on the same day, the physician performs a minor, separately billable procedure, such as an electrocardiogram (ECG) or a skin lesion removal.

In this scenario, the E/M service for the chest pain is unrelated to the knee surgery and falls within its global period, justifying Modifier 24. This E/M service for chest pain is also significant and separately identifiable from the ECG or skin lesion removal performed on the same day, thus warranting Modifier 25. Both modifiers would be appended to the E/M code for the chest pain. The E/M service for the chest pain must be distinct from any post-operative checks for the knee, and the minor procedure must also be separate from both the knee surgery and the E/M for chest pain.

Essential Documentation and Guidelines

Accurate and thorough documentation is essential when using Modifier 24, Modifier 25, and their combined application. The medical record must clearly support the distinct nature of the services rendered to justify separate billing. For Modifier 24, documentation needs to state that the E/M service provided during the global period is for a new or exacerbated condition unrelated to the original surgery. This includes using a diagnosis code unrelated to the surgical condition.

For Modifier 25, the documentation must demonstrate that the E/M service performed on the same day as a procedure was significant and separately identifiable. This requires a history, examination, and medical decision-making process that addresses a problem or condition distinct from the reason for the procedure. Even if the diagnosis is the same, the documentation must show that the E/M service involved additional work and medical necessity.

When both modifiers are used together, the documentation must outline how the E/M service meets both criteria: unrelated to the prior surgery (Modifier 24) and significant and separately identifiable from another procedure performed on the same day (Modifier 25). Each service must have its own distinct documentation within the patient’s record. Insufficient documentation is a primary reason for claim denials and audits.

Healthcare providers must adhere to payer-specific guidelines, as interpretations of modifier usage can vary. While the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) provide definitions, individual payers may have additional requirements or policies. Compliant billing and successful reimbursement depend on precise coding that reflects the medical necessity and distinctness of each service provided.