What is Modifier 27 in Medical Billing?

Modifier 27 is one of the most used 2-digit billing codes in hospitals. However, you have probably opened this guide because you recently faced a denial due to this modifier. Don’t worry, we have created this guide to clear all confusion and misconceptions.

We will explain everything in detail and also discuss some scenarios in which this code can be accurately applied to claim forms. So, let’s start. 

Modifier 27 – Description

The modifier 27 is defined as:

“Multiple outpatient hospital evaluation and management (E/M) encounters on the same date.”

Its usage can be a little confusing, so let’s break down this descriptor.

Modifier 27 became effective on October 1, 2001. It applies exclusively to hospital outpatient departments, including emergency departments, outpatient clinics, and critical care units. This modifier cannot be used by physician practices or other non-institutional providers. 

The primary purpose of modifier 27 is to communicate to payers that a hospital provided multiple, separate E/M services to the same patient on the same date of service. Without this modifier, insurance payers will reject your claims after seeing multiple E/M codes on the same claim. The important thing to note here is that 27 should be appended to the second and subsequent E/M service codes when multiple E/M services are rendered on the same day, not the first one. 

A common mistake that many billers make is that they use modifier 27 for all E/M billing codes. According to the CMS guidelines, this modifier should only be used for the following codes:

• Ophthalmological E/M services: 92002-92014
• Standard E/M services: 99201-99499
• Emergency Department Type A visits: 99281-99285
• Critical care services: 99291-99292
• Specific HCPCS codes: G0101 (cervical/vaginal cancer screening), G0175 (interdisciplinary team conference)
• Emergency Department Type B visits: G0380-G0384
• Initial preventive physical examination: G0402
• Hospital outpatient clinic visit: G0463

Modifier 27 – Usage Examples

Still confused? Let’s try to make things simpler with a couple of real-world scenarios in which modifier 27 can be used:

Emergency Department Visit Followed by Clinical Assessment

Suppose a patient comes to a hospital’s emergency department (ED) at 10 AM. He describes his condition to the ED physician as sudden and severe chest pain. The physician performs a comprehensive evaluation (CPT code 99284) and orders some diagnostic tests. The assessments and the test results show that the pain was due to gastroesophageal reflux rather than cardiac issues. Neccessary treatment is provided to the patient, and he is discharged by 2 PM. 

However, this same patient has a previously scheduled 4 PM appointment at the hospital’s diabetes management clinic for routine diabetes care and medication adjustment (CPT 99213). In this scenario, the hospital’s billing department can bill the CPT code 99284 for the ED visits and evaluation, and 99213 for the diabetes appointment. However, modifier 27 will be appended to CPT code 99213. 

Multiple Outpatient Specialty Consultations

Let’s consider another scenario. 

Suppose a man has a scheduled 9 AM ophthalmology appointment in the hospital’s eye clinic for diabetic retinopathy monitoring (CPT 92012). The ophthalmologist performs a comprehensive eye examination and determines that the patient’s condition is stable. Later that same day at 3 PM, the patient visits the hospital’s wound care clinic for evaluation of a post-surgical wound that shows signs of delayed healing (HCPCS G0463).

The hospital would bill 92012 for the ophthalmology service and G0463-27 for the wound care evaluation.

Accurate Usage Guidelines for Modifier 27

Using modifier 27 is simple. However, denials are still common. That’s because billers miss small details. The following are some essential points to consider when using this modifier in your hospital claims:

Follow the Billing Requirement

We have already mentioned that modifier 27 is exclusive for hospital and outpatient facility billing. Don’t use it for physician practices. Also, it must be reported on the UB-04 Part A claim form or its electronic equivalent (CMS-1450). Do not place it on the CMS-1500 form. 

Ensure Billing with Condition Code G0

According to CMS guidelines, the condition code G0 must be reported with the 27 modifier when multiple medical visits occur on the same day and in the same revenue centers. 

Provide Detailed Documentation

If you want your claims to be reimbursed, you must prove the necessity of using modifier 27. For this, you must provide detailed documentation with your claims that shows that the multiple E/M services were medically necessary and were distinct and separate from each other.

Always ensure to add the timestamps for each E/M session, complaints under each evaluation, patient symptoms, test results, observations during physical examination, and the medical decision-making. 

Final Thoughts on Modifier 27

Finally, we have reached the end of this guide. Let’s do a quick recap of the essential points. 

• Modifier 27 represents multiple outpatient hospital E/M encounters on the same service date.
• Make sure to append this modifier to the second and subsequent sessions and not the first one.
• Always use this modifier only for the approved list of CPT codes.

If you have any questions, feel free to reach out to our medical billing and coding experts. 

FAQs