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 (E/M) service by the same physician on the day of a procedure. Medicare views physicians in the same group with the same specialty as the same person.
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 simply 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 to remove it. You can bill the E/M visit with a 25 modifier, if appropriate.
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" or "over and above" the usual preoperative and post-operative services associated with the procedure and that the E/M service documentation can be identified separately.
What does that mean - significant and separately identifiable? Significant means a great amount of additional work over and above what you would normally provide prior to performing the procedure. Separately identifiable means that someone else looking at your documentation could see the significant E/M work separately from that which you provided in performing the procedure.
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 on the same day as 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.
Providers may use Modifier 25 in one other rare situation.
- The Evaluation and Management (E/M) service occurs on the day before a major procedure (090 days post operative time on the Medicare Physician Fee Schedule Relative Value File.)
- The E/M is not the decision for the major procedure, and
- The E/M is significant and separately identifiable from what would be included in the procedure.
A significant number of Medicare Redeterminations request the addition of modifier 25 to an E/M visit. Please check your records to verify you bill this modifier correctly and that you document the significant, separately identifiable service in your medical records.
Page Last Updated: Thursday, 18-Mar-2010 05:56:51 CDT
