According to American Medical Association (AMA), Modifier 25 is a significant, separately identifiable evaluation and management service performed on the same day as the procedure or other service by the same qualified health care professional. Even if the documentation is not required to submit with the claim, the physician must adequately and sufficiently document the medically necessary E/M service and the procedure to support the claim for these services in the patient’s medical record.
Billing and coding policies are typically based on Current Procedure Terminology (CPT) and Medicare requirements, which are not always consistent. Fortunately, the rules for modifier 25 are rather similar.
Significant and Separately Identifiable
An E&M is significant and identifiable from a procedure conducted at the same encounter if the work associated with the E&M and procedure do not overlap. National Correct Coding Initiative Policy Manual For Medicare Services states that a significant and separately identifiable E&M exists if it does not “include any work inherent in the procedure, supervision of others performing the procedure, or time for interpreting the procedure’s result.”
There must be no overlap in work between the E&M and the procedure to substantiate an E&M distinct from a procedure.
How To Use Modifier 25 Correctly
CPT modifiers add more information to claims processing. However, appropriate modifier usage is a key problem for hospitals and physician offices, so medical coding businesses pay close attention to it when reporting claims. CPT code modifier 25 is one of 83 target codes targeted for review by the Centers for Medicare and Medicaid Services (CMS) in the 2017 Medicare Physician Fee Schedule Proposed Rule.
When To Use Modifier 25
• Modifier 25 should not be appended to the procedure code and always associate the modifier with the E/M CPT code.
• It is not required to have two different diagnosis codes.
• Both the E/M service and the procedure must be adequately and sufficiently documented in the patient’s medical record.
• Modifier 25 should only be used in exceptional circumstances. According to ACS, E/M service the day before a major operation is a substantial, distinct service likely to be associated with a different diagnosis.
• The E/M service must be extensive and extend beyond the procedure’s pre-service period. Extended E/M work should be medically required.
• Modifier 25 may be added to E&M services combined with small surgical operations (global period of 000 or 010 days) or procedures not covered by global surgery regulations (a global indicator of XXX). Because small surgical operations and XXX procedures comprise inherent pre-, intra-, and post-procedure work, the provider should not report an E&M service for this work.
• Wound repair
• Drainage of skin abscess
• Biopsy of skin lesion
When To Avoid Using Modifier 25
According to ACC Modifier 25 should not be used in the following scenarios.
• When invoicing for services provided during a postoperative period connected to the previous surgery, do not use the 25 Modifier.
• If simply an E/M service and no treatment were performed during the appointment visit
• On the day of a “Major” (90-day worldwide) surgery, do not use a Modifier 25 on any E/M.
• When a minimal operation is conducted on the same day, do not add Modifier 25 to an E/M service unless the level of service can be justified as important and individually identifiable. All procedures feature an “inherent” E/M service.
• The patient was there for a routine operation.
Three Most Common Reasons for Modifier 25 Denial
Following are the three major factors for Modifier 25 denials.
• Inadequate documentation
• Incorrect coding
• Lack of medical need to support both codes billed by the same physician on the same day.
Modifiers are an important part of medical invoicing for health care services. With CMS indicating a greater emphasis on modifier 25 in the 2017 Physician Fee Schedule Proposed Rule, providers must evaluate their claims and evidence to verify that this modifier is not being exploited.
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