To Use Modifier -25 or Not To Use Modifier -25, that is The Question.

By Erica Schwalm

 

The correct use of modifier -25 is often an area of confusion for coders and providers.Misunderstanding this modifier can lead to loss of revenue and put your practice at risk for noncompliance.

 

When a provider performs a significant, separately identifiable E&M service on the same day as another service, the claim must be submitted with the modifier -25 or it will be denied.Consistently submitting without the modifier could result in a substantial loss of revenue.

 

On the other hand, submitting claims with the modifier -25 when it is not appropriate is considered to be a fraudulent practice.††

 

In order to prevent both of these situations, one must fully understand this modifier and when it is or is not appropriate to use.

 

Definition of modifier -25: Significant, separately identifiable E&M service by the same physician on the same day of a procedure or other service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patientís condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E&M Service may be prompted by the symptom or condition for which the procedure was provided. As such, different diagnoses are not required for reporting the E&M services on the same date. The circumstance may be reported by adding modifier 25 to the appropriate level of E&M service.

 

 

Myths about Modifier -25

 

1.AN E&M SERVICE WITH MODIFIER -25 SHOULD BE USED EVERY TIME A PATIENT (NEW OR ESTABLISHED) COMES TO THE OFFICE AND HAS A PROCEDURE.

Every procedure has some E&M elements involved with it.It may be necessary to assess the patientís vital signs or take a brief history.This does not mean you can report an E&M service.The E&M service must be significant and above and beyond the care that is normally associated with the procedure.††

2.MODIFIER -25 CAN ONLY BE USED IF THERE IS A DIFFERENT DIAGNOSIS.

The definition of modifier -25 clearly states that different diagnoses are not required for reporting E&M services on the same day as another procedure.As long as the E&M service was above and beyond what is usually required for the procedure, it may be reported separately with modifier -25.For example, a new 50-year-old patient presents to the office complaining of hip pain.After a detailed history and exam, the provider determines the patient has hip bursitis and decides to perform an injection to treat the bursitis.The E&M service in this case would most likely be above and beyond what is normally required for a bursa injection - The injection would not normally require a detailed history and exam, but in this case was felt to be medically necessary by the provider.Even though the diagnosis is the same, both services should be reported.

 

3.MODIFIER -25 CAN ONLY BE USED FOR NEW PATIENTS

The scenario above could also apply to established patients.In general, if the patient has already been worked up at a previous visit and is returning to your office for a scheduled procedure, it would probably not be necessary to perform another E&M service above and beyond the normal care associated with the injection.However, if the procedure was not planned ahead of time and it is medically necessary to perform an E&M service, it may be reported separately with modifier -25.For example, if the patient was established, but hadnít been seen in a while and hip pain was a new symptom, it may be necessary to perform a significant, separately identifiable E&M.In some circumstances, it may even be appropriate to report both services if the procedure was planned.If the patientís condition had changed significantly since the last visit or if other issues were addressed, a significant, separately identifiable E&M service may be necessary.

 

4.MODIFIER -25 SHOULD BE USED ON EVERY NEW PATIENT WHO HAS A PROCEDURE DONE.

Even if the patient is new, it does not necessarily mean an E&M service should be reported.For example, a new, otherwise healthy 18-year-old patient presents to urgent care for a 2nd degree burn on the hand from fireworks.The physician takes a brief history, examines the hand, and applies a dressing to the wound.This would most likely be reported with procedure code 16020.It would probably not be necessary to perform a significant E&M service in this case.

 

 

Questions to ask yourself before submitting modifier -25

 

1.Was the E&M service provided medically necessary and above and beyond what is normally required for this procedure or other service provided on the same day?

If the answer is no, then do not report an E&M service.If yes, see below.

 

2.Was the significant, separately identifiable E&M service properly documented?

If yes, report both services with modifier -25.If no, do not report E&M service.See below for documentation tips.

 

 

Documentation Tips

 

If the E&M service performed was truly significant, medically necessary, and above and beyond the care normally associated with the other service provided on the same day, it must be documented properly.One way to look at it is:Could you cut the documentation for the procedure or other service out of the notes with a pair of scissors and still be left with enough documentation to support a level of service?

 

Another way to document the services would be to record each service separately - a report for the E&M service and separate report for the procedure or other service performed.†††

 

Remember:If it isnít documented, it wasnít done!

 

 

 

 

 

 

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