The general guidelines on reporting modifier 25 with CMT codes are as follows:

• CMT codes include a pre-manipulation patient evaluation.
• Additional evaluation and management (E/M) services may be reported separately using modifier 25, if the patient's condition requires a separate E/M service, above and beyond the usual pre-service and post-service. So if manipulation and E/M codes are billed for the same visit, it is necessary to attach modifier 25 modifier to the E/M code.
• As the E/M service may be caused or prompted by the same symptoms or condition for which the CMT service was provided, different diagnoses are not required for the reporting of the CMT and E/M service on the same date.

The bottom line is modifier 25 should be used only when DCs perform an assessment above and beyond the adjustment.

The National Correct Coding Initiative (NCCI) edit program developed by the Centers for Medicare and Medicaid Services (CMS) is used by carriers and third party administrators in an effort to prevent improper payment when certain codes are submitted together. Modifier 59 and some other modifiers are exceptions to the NCCI PTP (procedure-to-procedure) edits.

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures and services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

CMS instructs that documentation should support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. Modifier 59 allows the claim to pass Medicare bundling edits, which would lead to additional reimbursement for the physician.