Coding Rules for Modifier 22, 23, 24 and 25

Modifiers play a very important role in procedure coding. As a medical coder, I have always struggled a lot in using modifiers. Even when I was preparing for my CPC exam, I was not much confident with the use of modifiers. But, after years of experience in medical coding, I have now gain confidence in coding modifiers. Today, we will learn about modifier 22, modifier 23, modifier 24 and modifier 25. These modifiers are frequently used and coders should always be prepared with these modifiers. If you are perfect with coding modifiers, you can easily clear AAPC exam like CPC in first attempt. Also, we will check the description, documentation and examples for these modifiers.

Table of Contents

Documentation/example to use Modifier 22

Increased Procedural Services

Modifier 22 is used for services which are greater than usual and which requires increased physician work above and beyond normal. Documentation supporting to describe the unusual circumstances of the procedure that made the service greater than the normal services, leads to submission of modifier 22 along with procedure or CPT code. Also, the time should be documented which actually requires to perform a procedure and the significant increase of the time used for performing the procedure. But do remember, modifier -22 should only be used along with surgery CPT codes, it should not be used along with E/M CPT codes. Modifier -22 is valid for CPT codes with global periods of 0, 10 or 90 days. Modifier -22 is not valid for “XXX” global period indicators, which includes E/M, radiology, laboratory, pathology, and most medicine codes.

For example, the removal of lysis of adhesion is included in laproscopic surgery cpt code 58660. But, when the documentation reflects the dense/extensive work was used for the removal of lysis of adhesions, modifier 22 should be appended in this scenario with the procedure code. The surgeon must give a clear picture describing the difficulty encountered in the procedure.

When to use Modifier -23

Unusual Anesthesia

When a service which requires local or regional anesthesia normally but due to unusual circumstances the anesthesiologist given general anesthesia to perform the procedure, in such cases Modifier -23 should be used. Modifier 23 is used along with Anesthesia codes (00100-01999). Only physician providing the general anesthesia should use Modifier 23, which is usually provided by anesthesiologist. The insurance company or the payer can ask for a written report for the need in clarification of using unusual anesthesia with modifier -23. For example, an elderly patient comes with a minor injury to a physician and the physician thinks of giving local anesthesia, but since the patient is aged he or she might get disturbed during treatment. Hence, to keep the patient stable during treatment the physician uses general anesthesia. So, in such circumstances you can assign modifier 23 along with the CPT codes for unusual anesthesia.

Key points with modifier 23

23 modifier may only be submitted with anesthesia CPT codes 00100 through 01999
Anesthesiologists, Certified Registered Nurse Anesthetists (CRNAs) or anesthesiologist assistants (AAs) should submit this modifier to indicate that a procedure that is normally performed under local anesthesia or with a regional block required general anesthesia
This modifier is informational only and does not affect reimbursement

When to use Modifier -24

Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Modifier-24 is used only with E/M codes. This modifier report services during the postoperative period which are unrelated to the surgery and should be considered separate from the surgical package. Surgical package (global period) includes preoperative, intraoperative and the normal follow-up care services during postoperative period. Most of the services related to the surgery during postoperative period gets included in the surgical package. But, when an Unrelated E/M service is provided to a patient during a postoperative period, it need to billed separately otherwise the payer will think it is included in the surgical package. Hence, to bill such unrelated E/M services modifier -24 is reported along with E/M codes during postoperative period. The global or postoperative period for major surgical procedure is 90 days and for minor surgery only 10 days. As I have already mentioned, the postoperative or follow-up care of the patient in global period is included in the payment of the surgical procedure. Modifier -24 can also be used with ophthalmological services codes 92002-92014 for eye evaluations. These codes may be located in Medicine section, but the ophthalmologists report their new and established patient services for medical examination using these service codes.

When to use Modifier 25

Significant, Separately Identifiable E/M Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

Modifier -25 is slightly different from Modifier 24. If you read the description of both Modifier 24 and modifier 25, you can easily make out the difference between these two modifiers. When two separate services including an E/m service and a procedure is performed together on same day by the same physician or other qualified health care professional, modifier 25 is reported only to E/M service code. Always remember, Modifier 25 should always be used along with E/M CPT codes. If you forgot to use 25 modifier with E/M CPT code, the payer will include the E/M service in the payment of the surgical procedure. Use of modifier -25 increases the potential of receiving payment for the service. The modifier can also be assigned when additional E/M services are provided on the same day to the same patient.