Using modifiers is a way of specifying that additional services were provided during an outpatient visit, beyond the primary code being billed. If modifiers aren’t used or are used incorrectly, this can lead to denial of payment for services provided. This section can't cover every available modifier, but will cover the most commonly used modifiers.
Modifier 25: Separate E/M service on the same day as another separately billable service.
This is the most commonly used modifier in family medicine, and is often used with a routine office visit (99203-99205//99213-99215) to show that an additional billable service was provided. This could be a procedure, such as an injection, skin biopsy/excision, cryotherapy, IUD placement, etc. However, it can also refer to other separately billable CPT codes, such as performing an ECG, spirometry, radiology, collecting labs, or administering immunizations.
Additionally, a -25 modifier may be used with a preventive visit to show an additional office visit for acute or chronic care was performed.
Examples:
Example 1: You see a patient for follow-up of hypertension and hyperlipidemia, refill some medications, and do a skin biopsy of a suspicious skin lesion. You bill the office visit (99214) with a -25 modifier, along with the CPT code for the skin biopsy.
Example 2: You see a patient for a preventative visit and also evaluate and manage uncontrolled hypertension and diabetes mellitus. You bill the preventative visit first, a -25 modifier, and the problem-based visit (99214).
Example 3: You see a patient for follow-up of osteoporosis and osteoarthritis, prescribe some medications, and then have a pneumococcal immunization administered. You bill the office visit (99214), with a -25 modifier, along with CPT code for vaccination administration.
Add on code G2211: This add-on code reflects the time, complexity/intensity of care, and practice resources required when physicians provide longitudinal care for patients in the outpatient setting. It should be used when you are providing a continuing focal point for health care services for a patient in the outpatient setting. Additionally, G2211 can be billed when billing 99202-99215 (new or established office visits).
You should not use the add-on G2211 code:
● When your relationship with the patient is of a discrete, time-limited nature, e.g., if you are seeing a patient for an acute concern, but you don’t assume responsibility for their ongoing medical care or don’t plan to take responsibility for subsequent ongoing medical care with continuity over time. For instance, you wouldn't bill G2211 for a visit occurring in a free-standing urgent care clinic that doesn’t provide continuity of care for that patient.
● If you report Modifier 25 (see above for details of when this modifier is used).
G211 became active for use on Jan 1, 2024 and further updated clarifications by CMS may occur in the future. For instance, the intention of not using G2211 along with modifier 25 is to avoid using it when patients are having a procedure, but it currently can't be billed if using modifier 25 when a patient has routine immunizations, x-rays, etc., during a routine office visit in a continuity clinic. Thus, at the time of this writing, requirements should be monitored for future updates.
Example 1: You see an established patient in a continuity clinic that is following up for evaluation and management of their hyperlipidemia, atrial fibrillation, and to discuss medication management. You bill 99214 and add-on code G2211.
Example 2: You see an established patient, with a history of hypertension, in a continuity clinic for acute influenza A and discuss their mildly elevated (uncontrolled) blood pressure, but say you aren't going to raise their antihypertensive medications, and will monitor it. You also recommend they don’t use over-the-counter decongestants (which can further raise their blood pressure) and recommend they get pneumococcal immunization after they recover from Influenza A. You bill 99214 and add-on code G2211.
Modifier 24: Unrelated E/M service during postoperative period.
After a procedure is done by you or someone in your billing group, there is typically a “global period,” a specified duration of time that varies by procedure. During this time, all related care is covered by the billing of the procedure (e.g., wound infection, dehiscence, related follow-up, etc.).
Note: Outpatient skin procedures have a global period of 10 days.
Example 1: You do a skin biopsy of a suspicious lesion and the global period is 10 days, during which time all care is covered related to the skin biopsy, per billing for the skin biopsy. However, the patient returns in 1 week for follow-up of uncontrolled hypertension. You bill the established office visit (99214), along with a 24-modifier, to make clear this visit is unrelated to the skin biopsy.
Modifier 50: Bilateral procedures
This modifier is used when performing bilateral procedures at the same time and when the procedure CPT billing code doesn’t already specify it is a bilateral procedure.
Example 1a: You perform bilateral knee corticosteroid injections for a patient at the same time in clinic, without ultrasound guidance (injecting 40mg of triamcinolone into each knee for a total of 80mg). You bill CPT 20610 x 2 (for left and right knee injections), J3301 x 8 (10mg of triamcinolone is considered 1 unit and you bill for each 10mg—thus you bill 8 units, for a total of 80mg), and you bill modifier 50, since you are doing bilateral procedures (right and left knee injection).
Example 1b: At the time of bilateral knee steroid injections in Example 1a, if you also addressed uncontrolled diabetes mellitus with medication management, you would then additionally bill 99214 with modifier 25 (in addition to billing noted in Example 1a). NOTE: You cannot bill G2211 since you are doing a procedure and using modifier 25.
Modifier 59: Distinct Procedural Service that indicates the service is separate and distinct from another service (not typically reported together on the same day, but appropriate). It's unrelated to the E/M. However, if any of the following newer, more specific modifiers are applicable, they should be used instead of simply listing modifier 59. Some of these may be uncommon and do not guarantee reimbursement:
Modifier 59 can be used to specify the following (along with modifier 59):
1. Modifier XE: separate Encounter—distinct service because it occurred during a separate encounter on the same day.
2. Modifier XP: separate Practitioner—distinct service because it was provided by a different practitioner on the same day.
3. Modifier XS: separate Structure—distinct service because it was performed on a different organ/structure on the same day.
4. Modifier XU: separate Unusual Non-overlapping Service—distinct service because it does not overlap the usual components of the main service on the same day.
Resident supervision specific modifiers: one of the following should be selected for every resident encounter:
1. Modifier GC: Teaching physician present or “sees” the patient. Think: with GC the teaching physician “sees” the patient (play on words) 🙂.
2. Modifier GE: Primary Care Exception. This applies after the first 6 months of residency training for certain billing levels, i.e., 99213/99203 or below and annual preventative visits. Think: GE has an “E” in it for Primary Care Exception. It can't be used for transitional care management visits or level 4-5 established/new office visits (99214-99215/99204-99205).