Modifiers 25 and 59
Modifiers are used to indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code.
Under normal circumstances, an Evaluation and Management service (E/M – exam) is filed without a modifier (99203 in this example).
However, if you adjust the patient on the same day as the E/M, a problem is created because the Chiropractic Manipulative Treatment (CMT – adjustment – 98940) includes a “Pre-manipulation patient assessment.” Without a modifier, the more expensive service (E/M) will be denied as a duplicate service. Your choices are:
- Do not examine and adjust on the same day (this has always been our recommendation)
- Don’t charge the patient for the adjustment.
- Modify the E/M service with a 25 modifier.
Modifier 25 is used to indicate that this is a significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day.
Unfortunately, modifying the E/M does not guarantee payment. Some insurance companies simply will not cover an E/M and CMT on the same day. And some will only consider payment if the E/M is for a new patient (99201-99205) not an established patient (99211-99215).
It’s important to note that modifier 25 only applies to E/M services.
A 59 modifier is used to indicate a significant, separately identifiable non-E/M service by the same physician on the same day.
A non-E/M service that is commonly used by chiropractors is Manual Therapy Techniques (97140). This includes mobilization/manipulation, manual lymphatic drainage and manual traction – one or more regions, each 15 minutes.
Since this code (97140) includes manipulation, it should be modified with a 59 modifier if it is performed on the same day as an adjustment (CMT).
Any manual therapy techniques performed cannot be in the same anatomic region as the adjustment in order for the manual therapy to be reimbursed.
Our Insurance Course includes much more information about how to use modifiers.