Modifier 25: When to Use, and When NOT to

Many healthcare providers (and sometimes even coders and medical billing companies) incorrectly believe that anytime an E&M (evaluation and management code, 99XXX series) is billed with another service, the modifier 25 needs to be appended to the E&M. The rationale behind Modifier 25 is that it communicates to the insurance carrier that the exam was significant and separate from the work involved in the other procedure performed on that day. The pricing value of a procedure is designed by the AMA/CMS/insurance carriers to include the work of the procedure itself as well as the preparation and post-service work/interpretation that is integral to the procedure itself.

When it is Inappropriate to Use: Time preparing for the procedure, advising the patient of what is about to happen, and the interpretation or post-work of the procedure do NOT qualify as time that can be billed as a separate and significant E&M service.

When it is Unnecessary to Use: Some procedures/services are inherently different than the nature of an E&M and thus CCI edits (Correct Coding Initiative) state that the E&M and the additional service can be billed without any need for a 25 modifier on the E&M.  An interesting (and confusing) example of this is OB/MFM ultrasounds. The CPT manual defines ultrasounds as separate from E&M’s, and coding edits clearly state that a modifier 25 is not needed on the E&M when billed with ultrasounds. The problematic aspect of this is that not all carriers honor the CPT/CCI guidelines for E&M and Ultrasound. Some carriers will still bundle payment of the E&M into the ultrasound if a 25 modifier is not used. In scenarios such as this, we advise that every provider, coder, and medical billing service know and understand the coding directives of CPT and CCI – AND – know and understand the unique exceptions that payers make. As we know, insurance carriers often play by their own rules.

CMS has provided this convenient checklist of when Modifier 25 can be used, and when it should be omitted and the E&M not separately billed:

Modifier 25 Check List

Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Often questions are posed regarding whether to bill an E/M visit on the same day as a procedure and/or other services with modifier 25.

Why is the patient being seen?

  • Were the physician’s or other qualified health care professional’s evaluation and management of the problem significant and beyond the normal preoperative and postoperative work?
    • Yes, an E/M may be billed with modifier 25
    • No, it is not appropriate to bill with modifier 25
  • Does the complaint or problem stand alone as a billable service?
    • Yes, an E/M may be billed with modifier 25
    • No, it is not appropriate to bill with modifier 25
  • Did the physician perform and document the key components of an E/M service for the complaint or problem?
    • Yes, an E/M may be billed with modifier 25
    • No, it is not appropriate to bill with modifier 25
  • Is there a different diagnosis for a significant portion of the visit? Or if the diagnoses are the same, was extra work above and beyond the usual preoperative and postoperative work associated with the procedure code?
    • Yes, an E/M may be billed with modifier 25
    • No, it is not appropriate to bill with modifier 25
  • Are there signs, symptoms, and/or conditions the physician or the other qualified health care professional must address before deciding to perform a procedure or service?
    • Yes, based on the documentation, an E/M service might be medically necessary with modifier 25
  • Was the procedure or service scheduled before the patient encounter?
    • Yes, it is not medically necessary to bill for an E/M
  • Is there more than one diagnosis present that is being addressed and/or affecting the treatment and outcome?
    • Yes, bill the procedure code and the E/M with modifier 25
    • No, it is not appropriate to bill with modifier 25

Modifier 25 Check List Source:  https://www.novitas-solutions.com/

 

 

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