modifier 25 : Oftentimes a patient’s “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more involved. When the provider goes above and beyond the physician work normally associated with a billable service or procedure, you may be able to report the separate evaluation and management (E/M) service with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended. But beware, this modifier, which indicates you should be paid for both services, has been under scrutiny for years. Read on to make sure you’re using it properly, as it can generate extra revenue.
Understand Modifier 25
All billable minor procedures already include an inherent E/M component to gauge the patient’s overall health and the medical appropriateness of the service. Since the decision to perform a minor procedure is included in the payment — the relative value unit (RVU) includes pre-service work, intra-service time, and post-procedure time — it should not be reported separately.
Append modifier 25:
only when a minor procedure or other service and a separate and significant E/M service were performed
- on the same patient
- by the same physician
- on the same date
modifier 25 indicates that additional reimbursement is needed to account for the extra E/M work. The key is recognizing when the additional work is “significant” and, therefore, additionally billable.
What’s Significant and Separately Identifiable?
It is only appropriate to report the E/M with modifier 25 if, in addition to the procedure, the physician performs an E/M service that is beyond the usual pre-, intra-, and post-procedure associated care. This tells the payer that a new or existing problem was addressed at the time of another service/procedure and the patient’s condition required work above and beyond the other service provided or the usual care associated with the procedure performed.
Determine Appropriate Use
Typically, if the E/M service is unrelated to the minor procedure (i.e., for a different concern/complaint), the E/M may be reported separately. Additionally, if the E/M service occurs due to exacerbation of an existing condition or other change in the patient’s status, that service may be reported separately if it is independently supported by documentation. When deciding whether modifier 25 should be appended, ask yourself the following questions:
Were the key components of a problem-oriented E/M service for the complaint or problem performed and documented?
Could the complaint or problem stand alone as a billable service?
Is there a different diagnosis for this portion of the visit?
If the diagnosis is the same, did the physician perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code?
Note, a different diagnosis code is not needed, and in some cases, the diagnosis code for the E/M code and the procedure code will be the same.
Justify Modifier 25
As with all matters of provider service billing, understanding the necessity and justification for services performed is mandatory. Particularly with modifier 25, clear, detailed physician documentation is key to demonstrating their thought process and supporting the medical decision making (MDM) involved during the course of the treatment rendered. The available documentation should describe an independent, stand-alone E/M service in addition to the procedure. While you don’t need separate notes, physically separating the documentation for the E/M service from documentation for any other same-day procedures or services may help.
The E/M service must be significant, the documentation must substantiate this, and the physician work must be medically necessary.
Payment hinges on the provider appropriately and sufficiently documenting both the medically necessary E/M service and the procedure in the patient’s medical record to support the claim for these services. The encounter note could include the history of present illness, comorbidities and their possible effects on the current condition, a medically-warranted examination, and MDM.
Make sure your providers show their extra cognitive work, as it will serve a critical role when the payer reviews the claim. If the note touches only briefly on the current issue and the need for the additional service or procedure, consider the E/M service to be part of the procedure and not separately billable.
Avoid Misuse of Modifier 25
Here’s a summary of things to consider before appending modifier 25 to an E/M code:
E/M Service
The same physician must provide the separate E/M service and the procedure or other service for the same patient on the same day. All providers who bill under the same National Provider Number (such as physicians who share an NPI in a group practice) are, from a coding perspective, the “same” provider.
The E/M service must be significant and separately identifiable, and the extended E/M work must be medically necessary. All procedures have an inherent E/M service included. Do not append Modifier 25 to an E/M unless the level of service can be supported as going above and beyond.
You do not need a separate diagnosis to justify a same-day E/M service with modifier 25. What must be documented is an appropriate history and exam, as well as a decision-making process that includes attention to more than the patient’s targeted chief complaint that is the reason for the minor procedure/service.
Global Period
Modifier 25 is appropriate when an E/M service is provided on the same day as a minor procedure; defined as one with a 0-day, 10-day, or “xxx” global period.
Do not use modifier 25 when medical billing for services performed during a postoperative period if related to the previous surgery. Related, follow-up examinations by the same provider during the global period of a previous procedure are included in that procedure’s global surgical package.
For an unrelated E/M service during the global period of a previous procedure, you may be able to report an appropriate E/M code with modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period appended. This would require that the E/M is for a new problem not related to the patient’s previous complaint or procedure.
Append modifier 57 Decision for surgery — rather than modifier 25 — if the E/M service prompts the decision to render a major procedure within 24 hours of the E/M service; major procedure is defined as one with a 90-day global period.
Check with your payer for coverage specifics and guidance on proper reporting.
Without a well-documented medical record, payers may render determinations of incorrect claim denials or underpayments. But with proper supporting documentation, even if a payer is incorrectly denying services, the billing staff will have a leg to stand on when filing claim reconsiderations.
For More Information: 84519 are you using modifier 25 correctly
