Difference between modifier 25 and 59
1. Modifier 25:
Significant, Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician on the Same Day of the Procedure or Other Service
| Feature | Modifier 25 | Modifier 59 |
| Used for | Evaluation and Management (E/M) services | Procedural services |
| Purpose | To bill an E/M service separately from a procedure performed on the same day | To indicate distinct procedural services, avoiding bundling |
| Application | Used with an E/M code when a procedure is also performed | Used with procedural codes (not E/M codes) |
| Typical Scenario | Patient receives an office visit and a procedure (e.g., an injection or minor surgery) | Two procedures are performed at different anatomical sites or times |
| Example | Office visit for a new medical condition + lesion removal | Two wound repairs on different body parts |
Purpose:
Modifier 25 is used when a provider performs a significant and separately identifiable Evaluation and Management (E/M) service on the same day as another procedure or service. It indicates that the E/M service is distinct from the procedure and should be reimbursed separately.
Typical Use Case:
A patient comes in for a preventive visit, but during the same encounter, the provider addresses a new or separate medical issue (e.g., a patient gets a routine check-up but also mentions knee pain, requiring an E/M service to evaluate the knee).
The provider performs a minor procedure (e.g., removing a skin lesion) and also provides a separate E/M service to evaluate another issue (e.g., addressing ongoing diabetes management).
Example:
A patient receives a skin biopsy (CPT 11102) and also has an office visit where a new medical condition is evaluated and managed (E/M code 99213). Modifier 25 is added to the E/M code 99213 to show that it is a distinct and separate service from the biopsy.
Key Points:
1. Applies only to E/M services.
2. Used when the E/M service is separate and distinct from a procedure performed on the same day.
3. Should not be used for minor procedures that are part of the standard evaluation for the procedure performed.
2. Modifier 59:
Distinct Procedural Service
Purpose:
Modifier 59 is used to indicate that two or more procedures are distinct and independent from each other, even though they may typically be bundled together under one payment. It is used to avoid bundling when procedures are performed on different anatomical sites or at different times during the same day.
Typical Use Case:
| Modifier 59 is applied when two procedures are typically considered part of one service but were performed separately on different anatomical locations or at different times during the same encounter. |
| For example, if a patient has two separate lesions excised on different parts of the body, the procedures might typically be bundled together under one CPT code, but Modifier 59 indicates that these procedures are distinct and should be billed separately. |
Example:
A patient has a wound on their hand (CPT 12002 – simple repair of superficial wound) and a separate wound on their leg, also requiring repair. Modifier 59 would be added to one of the codes to indicate that these are distinct services on separate anatomical sites.
