25 Vs. 59 – Which Modifier to Use and When?

Medical billing and coding is already quite confusing and hard. When you mix in modifiers, well, it only gets worse. Healthcare services aren’t always simple and straightforward. In fact, most of the time, they are quite complicated, involving several procedures and services.

While that’s great for the patient, medical billing and coding for those services becomes a big headache, as medical billers have to include extra codes and modifiers to properly explain the services. Two of the most commonly used and confusing modifiers are modifier 25 and modifier 59.

Let’s see what both of them mean and when you should use which modifier during medical billing and coding.

WHAT ARE MODIFIERS IN MEDICAL BILLING AND CODING?

As the name suggests, modifiers tend to modify or explain more about a certain situation or object. Similarly, in medical billing and coding, modifiers are used to disclose more information about the procedures and services performed. Sometimes, a patient may come in for one service, but after that, they may need to undergo another vital procedure as well. Or, it might not be a vital procedure, but perhaps a simple demonstration. Either way, they have to be billed for it.

However, their insurance company might not understand why they were billed for that additional service. That’s why medical billers use modifiers to further explain the circumstances or aspects of the service so that payers can’t deny their claims and the healthcare practitioners are fully paid what they are due.

Modifiers consist of two characters, which are usually numbers, such as modifier 25 and modifier 59. However, sometimes, they can include alphabets as well. These modifiers go at the end of the main medical codes as their main purpose is to expand on those.

WHAT IS MODIFIER 25?

Current Procedural Terminology (CPT) defines modifier 25 as when a healthcare practitioner provides a “significant” and “separately identifiable” “evaluation and management (E/M) service” “above and beyond” the other services provided by the “same practitioner on the same day of the service”. The primary aspects to focus on are the significant, significant identifiable, E/M service, and above and beyond.

WHAT IS MODIFIER 59?

According to CPT, modifier 59 in medical billing and coding denotes medical procedures and services “apart from E/M services” that are not usually identified together, but in certain cases, are appropriate to be reported together. If there is already another modifier that better explains that situation, that modifier should be used rather than modifier 59.

WHEN SHOULD YOU USE MODIFIER 25 AND MODIFIER 59?

When you should use modifier 25 and modifier 59 has been a source of confusion since long. In fact, the definition of modifier 59 had to be eventually revised in 2008 just so that the difference between the two modifiers is more apparent. Ignoring the technicalities, both modifiers are used to report services that were provided on the same day by the same physician. Sometimes, they can even be used together in a claim.

However, that doesn’t mean that they are the same or that they can be used interchangeably. If you go over both modifiers’ definitions again, you’ll notice the difference. Modifier 25 is used when a healthcare professional performs an E/M service and then another separately identifiable, entirely distinct, above and beyond, non-E/M or procedural service on the same day. Modifier 25 is always reported with the E/M service.

Therefore, the medical biller will report the initial E/M service code plus the modifier 25 and then the non-E/M service code to ensure that the practice is reimbursed fully for both services. In comparison, modifier 59 is always used with the non-E/M code. A modifier 59 is used when the healthcare practitioner provides an E/M service and then another non-E/M service that is usually not reported together but make sense under these circumstances.

Modifier 59 is also considered to be the last resort. Only when you can’t find any other modifier that explains the situation, you should use modifier 59. In addition to that, you should use modifier 59 with the smaller procedure or service so that it appears as a more inclusive service.

IMPORTANCE OF USING THE RIGHT MODIFIERS IN MEDICAL BILLING AND CODING

As mentioned earlier, modifiers like modifier 25 and modifier 59 further explain the circumstances behind the healthcare services availed. The more information and documentation there is, the lower are the chances of that claim being denied or rejected by the payer.

Moreover, it’s vital to use the right modifiers with the right codes because if there’s some discrepancy within the claims, it gives the insurance companies or payers a reason to reject your claim and simply delays your reimbursement. Since modifiers just expand on the codes they’re reported with, you might assume that you can just report them any way you want, and it won’t matter.

However, the truth is that even though most forms allow up to four modifiers ahead of the code, payers usually focus on the first two. Therefore, if you want a quick and more importantly, a complete reimbursement, you need to add the right modifiers at the right place.

FINAL THOUGHTS

All this sounds confusing and is much harder to report. That’s why it’s important that you rely on a competent medical billing company to handle your medical billing and coding. Such companies are much more experienced and skilled in handling medical billing and coding. They know all about these small technicalities related to modifiers and other coding guidelines.

As a result, they are able to file claims much more accurately with lower chances of errors and, consequently, denials. Ultimately, they make sure that your practice is reimbursed as soon as possible and paid the full amount due for all healthcare services rendered.

If you need help with your medical billing, payment, and collection, get in touch with us for our full medical billing services. We help take away from your work load when it comes to payments and documentation, so you have more time to devote to patient care.