Modifier 24: For a Separate Check-Up After Surgery
Think of this modifier when a patient comes in for a routine follow-up after a surgery, but they also have a completely new health problem that isn’t related to the surgery.
Example: A patient is seeing their surgeon for a scheduled check after knee surgery. During the visit, they also mention a new headache. If the doctor evaluates and manages this headache, they would use modifier 24 on the billing code for the headache visit.
Why we use it: This tells the insurance company that the visit for the headache is separate from the usual care included after the surgery. This helps the doctor get paid for addressing the new problem.
Modifier 25: For a Significant Check-Up on the Same Day as a Procedure
Use this modifier when you perform a significant and separate evaluation and management (E/M) service on the same day you do a procedure. The patient’s problem during the E/M visit must be substantial enough to warrant a separate, identifiable service beyond what’s typically included in the procedure.
Example: A patient sees their heart doctor because of chest pain and is diagnosed with a heart issue. On the same day, the doctor performs a stress test to confirm the diagnosis. The doctor would use modifier 25 on the billing code for the initial evaluation and management of the chest pain.
Why we use it: This modifier clarifies that the initial assessment and management of the patient’s chest pain was a significant service on its own, not just a routine part of doing the stress test. It ensures the doctor is appropriately reimbursed for this extra work.