Podiatry Billing Guide

Modifier Usage

25 – Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service

Medicare allows payment for an E/M service performed on the same day as a minor surgical procedure, if all requirements are met. The term surgery or service includes therapeutic injections and wound repairs. The additional E/M service must be separately identifiable from the surgical procedure and require significant effort above and beyond the usual pre and post procedure service routinely required for the procedure. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. Medical records should document the E/M service to such an extent that, upon review, the extra effort may be readily identifiable. Note: The diagnosis may be the same for both the E/M and the surgery/procedure.

24 – Unrelated E/M Service by the Same Physician During a Postoperative Period

An E/M service coded with modifier 24 indicates a visit in the postoperative period that is unrelated to the original procedure (surgery). This modifier is only to be used with an E/M visit. It is not valid when used with surgeries or other types of services. It is not necessary or appropriate, for modifier 24 to be used with tests done in the postoperative period. When using modifier 24, ensure that the patient’s records and ICD-10 codes recorded on the claim clearly indicate that the E/M visit is unrelated to the original procedure.

57 - Decision for Major Surgery

An E/M examination code with modifier 57 indicates a visit that resulted in the initial decision to perform a major surgery. Surgeries that have a 90-day follow-up period are considered major surgeries. When coding modifier 57, ensure that the patient’s records clearly indicate when the initial decision to perform the surgery was made. Do not use modifier 57 with an E/M performed on the same day as minor surgery.

59 - Distinct Procedural Service

Modifier 59 is defined as a “distinct procedural service.” Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service performed on the same date, see modifier 25.

Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician.

CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as X[EPSU] modifiers) to define specific subsets of the 59 modifier:

XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter,
XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,
XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

CMS will continue to recognize the 59 modifier, but notes that CPT instructions state that the 59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the 59 modifier in many instances, it may selectively require a more specific X(EPSU) modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the XE separate encounter modifier but not the 59 or other X(EPSU) modifiers. The X(EPSU) modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line.

Reviewed 9/13/2024