Novice Know How - Appropriate Usage of Modifier 25
Editor's Note: This is the third in a series of monthly articles that focus on education to new providers. Please watch our Website, Communiqués, and Listserv for future articles.
The Current Procedural Terminology (CPT) defines modifier 25 as a significant, separately identifiable evaluation and management service by the same physician on the day of a procedure.
Does this situation sound familiar? Your patient comes in on the day of a scheduled procedure and says, "Oh by the way.." If your encounter, instead of being a scheduled procedure, turns into something more, you can bill Medicare for the E/M visit by adding modifier 25 to the E/M procedure code if appropriate.
This also applies to the situation when your patient comes in for a visit; you perform the E/M and then decide to perform a minor surgery. For instance, your patient comes in for a follow-up for uncontrolled hypertension. You perform the E/M visit, decide to change the medication and then your patient brings to your attention a skin lesion. You examine the lesion and decide it needs to be removed. You can bill the E/M visit with a 25 modifier, if appropriate, for the removal of the lesion.
Please note that in both situations above, you are stating that the patient's record clearly documents the E/M visit was "significantly more than" the usual preoperative and post-operative services associated with the surgical procedure and warrants the use of modifier 25.
What does that mean - significant and separately identifiable? Ask yourself - "Was the E/M I performed above and beyond the usual preoperative and post-operative services for the procedure?", "Could I bill the complaint or problem separately?", "Are the key components of a billable E/M service identified?" If yes, then you can bill the appropriate level E/M visit with modifier 25 and receive reimbursement for your services. If not, then the E/M visit is part of the procedure and not reimbursed separately.
When a significant, separately identifiable E/M visit on the day of a procedure, falls within the post-operative period of another unrelated procedure, both the 24 and 25 modifiers are necessary to document the services as payable.
Appropriate usage of modifier 25 is important. Remember to use modifier 25 on the E/M service only when billed with a procedure that has global days (000, 010 or 090) and the patient's records clearly document that the E/M visit was a significant and separately identifiable service.
A significant number of Medicare Redeterminations request the addition of modifier 25 to an E/M visit. Please check your records to make sure you are billing this modifier correctly and that the separately identifiable service is well documented in you medical records.
Page Last Updated: Monday, 09-Jun-2008 13:34:38 CDT
