Physician's Coding Strategist

Understanding modifiers a key to better coding

How does modifier -25 differ from -26?

Normally, Medicare only pays physicians once for a specific service provided to a specific patient per day. However, there are exceptions that are usually noted by placing a modifier on a code.

Here’s a primer on how to use these modifiers correctly:

  • Modifier -25 (new patient visit).

Modifier -25 is primarily designed for use with a new patient visit or a consultation, which is usually for a new patient. The usual justification for using this modifier is when a physician does the entire work-up of the patient, and a procedure is performed as a result of the work-up.

Tip: Most practices get into coding trouble for using modifier -25 with an established patient.

  • Modifier -26 (professional component).

If not correctly used, modifier-26, professional component, can produce both undercoding and overcoding. For instance, the global package for certain radiological procedures includes the technical and professional component. If a physician performs a fluoroscopy, and you include modifier -26, this indicates the physician both owns the equipment and interpreted the fluoroscopy data.

Because Medicare pays more for the owning or leasing of equipment than for interpretation, you would be overcoding if you used modifier -26 and your facility did not really own the equipment. However, if you own the equipment and use modifier -26, you would be undercoding.

  • Modifier -50 (bilateral procedure).

Superbills make this one of the most misused modifiers in anesthesia, say experts. Many physicians, for example, think each time they perform a separate injection it is counted as an additional procedure. But superbills are designed to have a first level and then subsequent levels of service.

For example, say a physician does a bilateral injection at two levels, meaning she gives four injections. The doctor then writes on the superbill the primary procedure times one and additional levels times three. However, this really should have been coded as the primary procedure times one plus modifier -50, and a subsequent level times one plus modifier -50.

  • Modifier -59 (services not usually performed together).

This modifier is used to identify services not usually performed together except in certain circumstances. Reasons why two procedures or services that are not normally reported together might be included on the same UB-92 form include:

  • separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician;
  • different session or patient encounter;
  • different procedure or surgery;
  • different site or organ system;
  • separate incision.

After an extensive surgery, for instance, you can use modifier -59 to inform the Medicare fiscal intermediary that the additional procedure codes are not being inadvertently duplicated on the UB-92.

The two biggest misuses of modifier -59 are using it to report a CPT/HCPCS code that is mutually exclusive when reported with another code and using it to report a CPT/HCPCS code that is a component of another code.

Here are some questions you should ask yourself to determine if the -59 modifier should be used in specific situations:

  • Do any of the codes violate the correct coding initiative edits?
  • If yes, is modifier -59 appropriate to explain the violation?
  • Are any of the codes being repeated for this case?
  • If yes, would modifier -59 be appropriate to explain the duplication?
  • Do any of the codes have "separate procedure" in their narrative description?
  • If yes, would modifier -59 be appropriate to explain that in this case, the "separate procedure" is not an integral component of some larger procedure?