What Is Modifier 27 and When Should You Use It?

Medical coding modifiers are an important part of healthcare billing, acting as additional information appended to a Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code. These two-digit additions clarify specific circumstances that alter a service or procedure without changing its core definition. Modifiers help ensure accurate claims processing by providing payers with a clearer picture of the services rendered. Their correct application is crucial for healthcare providers to receive appropriate reimbursement and maintain compliance.

Understanding Modifier 27

Modifier 27 officially stands for “Multiple Outpatient Hospital E/M Encounters on the Same Date.” This modifier is used exclusively by hospital outpatient departments, such as emergency rooms, clinics, and critical care units, to indicate that a patient received more than one distinct evaluation and management (E/M) service on the same calendar date. It signifies that these E/M services occurred during separate and distinct encounters, even if provided by different healthcare professionals.

A “separate encounter” in this context refers to situations where the patient leaves the facility and returns later the same day, or when distinct E/M services are provided for different clinical reasons. For instance, a patient might visit an emergency department for one issue, be discharged, and then return hours later for an unrelated problem. This modifier is specifically for facility billing, meaning it applies to the hospital’s charges for resources used (like the room, equipment, and nursing staff), not the professional services billed by a physician. It is not used on CMS-1500 claim forms, which are for professional services, but rather on UB-04 Part A claim forms or their electronic equivalents.

Applying Modifier 27

Modifier 27 is appended to the second and any subsequent E/M service codes on the same date to signal to payers that these services are distinct and not merely duplicative. This modifier helps justify multiple E/M services on a single day, ensuring the hospital is reimbursed for each separate use of its resources. The goal is to accurately reflect the separate utilization of hospital resources for distinct patient needs.

Consider a patient who arrives at an emergency department for chest pain evaluation, is treated, and discharged. If that same patient returns later the same day with a new complaint, such as abdominal pain, the E/M service for the abdominal pain would be reported with Modifier 27. Another scenario might involve a patient visiting an outpatient clinic for a routine follow-up, then experiencing a fall within the clinic and requiring a separate E/M service for a resulting headache. In this case, the E/M code for the headache evaluation would carry Modifier 27, as it represents a distinct encounter from the scheduled follow-up.

Modifier 27 can be used with various E/M service codes, including those for ophthalmological services, emergency department visits, critical care, and hospital outpatient clinic visits. When multiple medical visits occur on the same day in the same revenue centers, Modifier 27 is often reported along with condition code G0 on the UB-04 claim form. This combination further clarifies to the payer that multiple, distinct encounters took place.

Important Considerations

Accurate use of Modifier 27 requires documentation in the patient’s medical record. The records must clearly distinguish each separate encounter and the distinct medical reasons for each service provided. Without documentation, claims may be denied, as payers need to understand why multiple E/M services were necessary on the same day.

Payer-specific guidelines should be reviewed, as some insurance companies may have unique rules or preferences regarding Modifier 27’s application. While Modifier 27 is specific to hospital outpatient services, it is distinct from Modifier 25, which is used by physicians to indicate a significant, separately identifiable E/M service performed on the same day as a procedure. Modifier 27 should not be applied to services that are multiple within a single, continuous encounter, or for professional services billed by a physician. Its application is limited to facility billing by hospital outpatient departments.

Applying Modifier 27

Modifier 27 is appended to the second and any subsequent E/M service codes on the same date to signal to payers that these services are distinct and not merely duplicative. This modifier helps justify multiple E/M services on a single day, ensuring the hospital is reimbursed for each separate use of its resources. The goal is to accurately reflect the separate utilization of hospital resources for distinct patient needs.

Consider a patient who arrives at an emergency department for chest pain evaluation, is treated, and discharged. If that same patient returns later the same day with a new complaint, such as abdominal pain, the E/M service for the abdominal pain would be reported with Modifier 27. Another scenario might involve a patient visiting an outpatient clinic for a routine follow-up, then experiencing a fall within the clinic and requiring a separate E/M service for a resulting headache. In this case, the E/M code for the headache evaluation would carry Modifier 27, as it represents a distinct encounter from the scheduled follow-up.

Modifier 27 can be used with various E/M service codes, including those for ophthalmological services, emergency department visits, critical care, and hospital outpatient clinic visits. When multiple medical visits occur on the same day in the same revenue centers, Modifier 27 is often reported along with condition code G0 on the UB-04 claim form. This combination further clarifies to the payer that multiple, distinct encounters took place.

Important Considerations

Accurate use of Modifier 27 requires documentation in the patient’s medical record. The records must clearly distinguish each separate encounter and the distinct medical reasons for each service provided. Without documentation, claims may be denied, as payers need to understand why multiple E/M services were necessary on the same day.

Payer-specific guidelines should be reviewed, as some insurance companies may have unique rules or preferences regarding Modifier 27’s application. While Modifier 27 is specific to hospital outpatient services, it is distinct from Modifier 25, which is used by physicians to indicate a significant, separately identifiable E/M service performed on the same day as a procedure. Modifier 27 should not be applied to services that are multiple within a single, continuous encounter, or for professional services billed by a physician. Its application is limited to facility billing by hospital outpatient departments.