Monday, July 26, 2010

E & M - cpt codes and modifiers

E&M Codes

E&M codes are represented by CPT® code numbers 99201 through 99499. E&M codes are used to describe patient visits and are divided into broad categories such as office visits, hospital visits and consultations. These categories are then divided even further.

For instance, office visits are categorized as either new or established patients, and hospital visits are categorized as either initial or subsequent. And finally, within each subcategory there are different levels. These levels indicate the varying degrees of effort, time, responsibility and medical knowledge expended during the visit.

The E&M codes have their own set of modifiers should there be a special circumstance surrounding the visit. You must use one of these modifiers to describe the circumstance and indicate to your carrier that your billing is, therefore, modified.

E & M Modifiers

-24 Unrelated E&M Service by the Same Physician During a Postoperative Period
-25 Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service
-57 Decision for Surgery

Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of
the Procedure or Other Service: 

It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. 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 (see Evaluation and Management Services Guidelines for instructions
on determining the level of E/M service.) The E/M service may be prompted by the symptoms or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same day. The circumstances may be reported by adding modifier 25 to the  appropriate level of E/M service. 

Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable nonE/M  services, see modifier 59.

E/M with Preventive Medicine Visit

CPT guidelines for preventive medicine state; “If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem oriented E/M service, then the appropriate E/M service should also be reported.”

An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.

According to NCCI: The CPT Manual defines modifier 25 as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service”. Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s). 

Critical Care

Critical care services furnished  during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances.

Pre-operative and post-operative critical care may be paid in addition to a global fee if:

• The patient is critically ill and requires the constant attendance of the physician; and

• The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.
Such patients are potentially unstable or have conditions that could pose a significant threat to life or risk of prolonged impairment.

In order for these services to be paid, two reporting requirements must be met:

CPT codes 99291/99292 and modifier “-25” for pre-operative care or “-24” for post-operative care must be used; and 


  1. we have a 99213 by one provider FOR 8.11.16. 99233 BY ANOTHER PROVDER IN THE SAME GROUP FOR SAME DATE billed under group tax id. 99233 requiring modifier. tried 59 got denied. any suggestions please. thanks

  2. Hi,
    Modifier 59 can be used with the surgical codes where multiple surgeries has been performed same day, 59 modifier can never be used with E&M Services. In your case I don't think any modifier should be appended along with the codes as only one E&M service will be get paid by the Insurance Co. billed under same Tax id on same day.

  3. Hello. I have a query. If a Workman comp patient came in before lunch for a knee issue then did a followup for a different issue (different WC claim/case file) can we bill for two distinct encounters? They are billed under two different claim numbers since they are two different body parts.


  4. Addendum: The followup was after the lunch break, essentially, a different encounter.

    Thanks in advance for any help.


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