Things to know about Modifier 25

Things to know about Modifier 25

Modifier 25 is a particularly meaningful coding tool for physicians who bill for evaluation and management (E/M) services. CPT guidelines define the 25 modifier as “Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.”

Modifiers are valuable coding tools that explain to payers the specific work that was done by a physician during treatment of a patient.

In provider service billing, it’s important to understand the necessity of justification of service performed is mandatory. Clear detailed physician documentation is key to supporting the MDM involved during the course of the treatment rendered.

When E/M not to Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57. On the other hand, CPT defines procedures with a 0 or 10 day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately.

For review, common dermatologic procedures with 0 day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10 day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

Rules to Remember When Using the Modifier 25

  • Modifiers are needed to inform third-party payers of circumstances that may affect the way payment is made – the modifiers tell a story of what is actually being done!
  • Always link the modifier to the E/M CPT code
  • It is not necessary to have two different diagnosis codes
  • Need to document both the E/M and the procedure

According to CMS guidelines; Modifier 25 may be appended only to E/M service codes and then only for those within the range of 99201-99499. For outpatient services paid under OPPS, the relevant code ranges are:

  • 99201-99215 (Office or Outpatient Services)
  • 99281-99285 (Emergency Department Services)
  • 99291 (Critical Care Services)
  • 99241-99245 (Office or Other Outpatient Consultations)

The pulmonary function tests are reported without an E/M service code. However, an E/M service code with the modifier –25 appended should be reported to indicate that the afternoon hypertension clinic visit was not related to the pulmonary function testing.

Medicare requires that modifier 25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). 

Use of Modifier 25 in Association with Hospital Outpatient Services

  • Modifier 25 applies only to E/M service codes and then only when an E/M service was provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). In other words, modifier –25 does not apply when no diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s) is performed.
  • It is not necessary that the procedure and the E/M service be provided by the same physician/practitioner for the modifier 25 to apply in the facility setting. It is appropriate to append modifier 25 to the qualifying E/M service code whether or not the E/M and procedure were provided by the same professional.
  • The diagnosis associated with the E/M service does not need to be different from that for which the diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s) was provided.
  • It is appropriate to append modifier 25 to ED codes 99281-99285 when these services lead to a decision to perform diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s)

The bottom line is to maximize your efficiency seeing patients and maximize their convenience in your medical home by providing medically necessary E/M 25 services at the time of another significant and separate E/M service or procedure. However, know your payer and its policy with this complicated coding area. You always prefer to get the payment for the work you do and you can focus on your work.

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