How to Apply Modifiers to Codes for E/M Services

Evaluation and management codes refer to medical procedure codes that identify the level of an encounter with a patient. The E/M code assigned for the visit with the physician depends on the medical facility where the patient was seen, whether the patient was new or established and the level of service provided during the office visit by the physician. Modifiers can be added to procedure codes to identify additional circumstances related to a procedure or E/M code. The right modifier can earn the physician additional reimbursement on a claim, whereas the wrong modifier can result in a claim being denied.

Things You'll Need

• Current Procedural Terminology (CPT) code book

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Instructions

• 1

  Refer to the modifiers in the front cover of the CPT manual. The most common modifiers are listed there. Some modifiers cannot be used with evaluation and management codes.

• 2

  Use a modifier 24 if a separate evaluation and management service was provided to the patient by the same doctor during a post-operative period, which is typically 90 days.

• 3

  Use a modifier 25 in addition to the E/M code when a separately identifiable service was also performed on the patient by the same physician on the same day as another procedure or service.

• 4

  Use a modifier 32 when the service is mandated for the patient by an organization such as workers' compensation or visit for a pre-employment drug screening.

• 5

  Use a 57 modifier when the initial office encounter with the physician resulted in the decision for the patient to undergo surgery.

• 6

  Use a 76 modifier when a repeat service or procedure is provided to the patient by the same physician.

• 7

  Use a 99 modifier when two or more modifiers are being used. The 99 modifier would be listed on the first listing of the E/M code, then the other E/M codes would be listed with their specific modifiers.

• 8

  Use Level II HCPCS modifiers to identify the area of the body affected, if applicable. Most insurance companies do not require the use of these modifiers, but each insurance company follows different guidelines. This is required for Medicare and Medicaid patients.