Modifier 25 vs. 59: Which to Use–and When

Rehab therapy billing: It’s a total numbers game. Between CPT codes and billing modifiers, knowing which digits belong on a claim is no simple task. After all, rules seem to change with the seasons, and they often vary from payer to payer. Here on the WebPT Blog, we receive a lot of comments and queries in response to these ever-changing rules, and one of the hottest points of confusion these days is the difference between modifier 59 and modifier 25. When applied to CPT codes, both modifiers indicate that two services—billed on the same date of service but not typically billed together—were separate and distinct from one another. But, while these modifiers may be similar, they are not the same—and it’s crucial to know when and how to use each. To that end, here’s the 411 on 59 and 25:

What is Modifier 59?

According to the CPT manual, modifier 59 indicates a “distinct procedural service.” Specifically, a provider can use the 59 modifier to indicate that he or she performed a service that was distinct and independent from all other services performed during the same session. Even more specifically, a provider would use this modifier to justify billing a pair of codes that ordinarily would not be billed together. As we explain in this modifier 59 blog, these “edit pairs” (as they’re called by the National Correct Coding Initiative [NCCI]) are sets of procedures that therapists commonly perform together. (You can get the full list of edit pairs, as well as guidance on which ones are modifier 59-eligible, in this blog.)

If your claim contains codes that form an edit pair—and you don’t include the appropriate modifier—the payer will only reimburse you for one of the procedures, “because the payer will assume that one of the services was essentially ‘built into’ the other.”

When Should You Use Modifier 59?

If you’re a rehab therapist, you should use modifier 59 when:

1. You bill for two services that form an NCCI edit pair, and you provided those services independently from one another.
2. The insurance payer recognizes NCCI edits.
3. Your documentation supports that you performed those services separately and distinctly of one another.

If you’re still unsure of whether you should use the 59 modifier, check out this blog post.

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What is Modifier 25?

As this article from HCPro states, the CPT-4 Manual defines a modifier 25-eligible service as a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service." Use of this modifier implies that on the day a service was performed, the patient’s condition required a separate and independent E/M service above and beyond the other procedure.

When Should You Use Modifier 25?

Simply put, providers should only ever use modifier 25 in conjunction with an E/M code—specifically, those within the range of 99201-99499. Because it’s highly unusual for rehab therapists to submit E/M codes, they generally should not use modifier 25. But, should you ever need to use modifier 25, you must ensure your documentation supports it completely.

So, there you have it: your quick guide to modifiers 59 and 25. Still have burning questions about either one of these modifiers? Drop them in the comment section below!