MODIFIERS 59, 25 AND 91: A GUIDE FOR CODERS
Little things can make a big difference regarding smooth medical billing payments or administrative hurdles. Several necessary codes, like modifiers 59, 25, and 91, make this process smooth and hassle-free. They act as translators between physicians and insurance companies, ensuring that both sides understand each other clearly so that physicians are paid accurately.
These modifiers can enhance billing besides ensuring proper payment to physicians.
What are modifiers in medical billing?
Modifiers add necessary details to the primary codes describing a doctor’s services, ensuring that the exact kind of treatment is recorded. These modifiers help healthcare providers show a patient’s visit more accurately, which leads them to get the correct payment for their service.
There are various modifiers, each serving a different purpose depending on the specifics of the service provided.
Modifier 59
Modifier 59 is not simply an add-on code. It signals that a physician has performed multiple services in one session, yet they are different and separate.
How does it work?
In medical service billing, primary procedure codes indicate the main services. If an additional procedure or service is not linked with the primary service, Modifier 59 is added to the code of the other service.
Application Steps
- Detect any procedures or services not typically linked with the primary one.
- Attach Modifier 59 to the code of additional service.
- It clarifies that the extra service is separate and not part of the leading service.
When to use
- A procedure or service is done again by the same doctor after doing a related procedure on the same day.
- When the following procedure is not connected to the first one, it happens in the same session.
Modifier 25
The following important modifier in medical billing is Modifier 25. It indicates that a physician has provided a substantial, separately identifiable E/M service on the same day a procedure is provided. This code ensures that the E/M service and the procedure for which the code is used are adequately paid for.
How does it work?
In case a patient has a planned procedure and requires an extra unrelated E&M service, Modifier 25 is added to the E&M service code. This notifies the insurance company that the consultation was distinct from the main procedure.
Application Steps
- Begin with the Scheduled Procedure and primary procedure code billing.
- Attach Modifier 25 to the E&M service code.
- Notify the insurer that the E&M service was separate and not combined with the main procedure.
When to use
- When a doctor gives management (E/M) service on the same day as an essential surgery.
- When a patient gets admitted to the hospital for observation, the physician gives an important identifiable E/M service.
Modifier 91
Modifier 91 indicates that a lab test was done more than once on the same day for a patient. This does not mean it was just a repetition, but it was needed to get subsequent follow-up on test results.
How does it work?
If a lab test needs to be done several times in one day for a patient, like when tracking changes in blood glucose levels, Modifier 91 is attached to the code of this lab test. This indicates that these additional tests are not merely repetitions but necessary follow-ups.
Application Process
Bill the primary lab test code for the first instance.
- Understand the necessity of conducting the same laboratory test several times daily.
- Append Modifier 91. Do this step for each subsequent lab test code.
- Notify the Insurance company that the tests were necessary follow-ups, not just repeats.
When to use
- To manage the patient’s treatment when you repeat a clinical laboratory test on the same service date.
- When you require several serial laboratory tests to treat a patient, For example, the need to repeat blood glucose tests.
Conclusion
Knowing and adequately using Modifiers 59, 25, and 91 is crucial for accurate medical billing. This helps ensure that healthcare services are reimbursed correctly, especially when different services seem similar but are distinct in nature and necessity. While Modifier 59 explains many separate services in one session, Modifier 25 shows vital, identifiable E&M services on the same day as other procedures. Modifier 91 marks vital repeated lab tests within a single day.
