Understanding Modifier 25 and Modifier 24: Differences and Uses in Medical Billing

Modifier 25 

Modifier 25 is a billing modifier used in the healthcare industry to indicate that a significant, separately identifiable evaluation and management (E/M) service was performed by a healthcare provider on the same day as another procedure or service. 

It is used when a patient’s visit involves both a distinct E/M service, such as a consultation or office visit, as well as a procedure or other service, such as a minor surgery or diagnostic test. 

 To qualify for modifier 25  

The E/M service must be above and beyond what is typically associated with the procedure or service being provided. It should be documented and billed separately from the other service, with its own separate diagnosis code and supporting medical documentation.

The use of modifier 25  

It helps ensure that providers are appropriately reimbursed for the extra time and effort involved in providing both an E/M service and another procedure or service on the same day. 

Do’s 

It should always be used along with E/M CPT codes. 

Modifier 25 Modifier 24 Apple Billing and Credentialing

Modifier 24 

Modifier 24 is used to indicate that an unrelated evaluation and management (E/M) service was provided by the same physician or qualified healthcare professional during a post-operative period. 

When a patient undergoes a surgical procedure, there is typically a designated period after the surgery known as the post-operative period. The global or postoperative period for major surgical procedure is 90 days and for minor surgery only 10 days. During this time, the physician or qualified healthcare professional provides follow-up care related to the surgery, such as wound checks or medication management. These services are considered part of the global surgical package and are typically reimbursed as part of the surgical fee. 

However, if a patient needs an unrelated E/M service during the post-operative period that is not related to the original surgery, the physician or qualified healthcare professional can report this service separately using modifier 24. This allows them to be reimbursed for the additional E/M service in addition to the reimbursement for the surgical procedure. 
 

To qualify for this modifier 24 

The E/M service must be for a different problem or issue than the one addressed in the original surgery. The documentation should clearly support the medical necessity of the separate E/M service. 

The use of modifier 24  

It helps ensure that providers are appropriately reimbursed for unrelated E/M services provided during the post-operative period following a surgical procedure. 

Do’s  

It should always be used along with E/M CPT codes.

 In summary, modifier 24 is used for unrelated E/M services during the post-operative period of a surgery, while modifier 25 is used for separate and significant E/M services performed on the same day as a procedure or service. Careful documentation is necessary to support the use of these modifiers and ensure appropriate reimbursement.