Don’t forget to append modifier 25 when warranted, or payers will consider your evaluation and management (E&M) service as part of a procedure, and not pay for it.
For example, Novitas Solutions reports it frequently receives requests from practices who need to correct a Medicare claim by adding modifier 25 to an E&M code.
Modifier 25 identifies a significant, separately identifiable E&M service for the same patient by the same physician on the same day of a procedure or other service. Practices forget that without the modifier (and supporting documentation), Notivas and other payers will treat the E&M service as part of the procedure or other service and not pay for it separately. (Note: “Same physician” includes physicians in the same group practice who are in the same specialty.)
Follow these tips for using modifier 25:
- Even if the E&M service and the procedure are clearly separate you need to add modifier 25 to the E&M code — never to the procedure code — that you’ve reported to the appropriate level.
Example: A patient comes in for a regular follow-up visit for hypertension and diabetes. The physician examines the patient and adjusts medications. During the visit, the patient asks the doctor to look at a cut on his hand. The cut, which has become infected, needs two stitches and an antibiotic. In this case, the E&M for hypertension and diabetes gets a modifier 25.
- You don’t necessarily need a separate diagnosis to justify using modifier 25 with a same-day E&M service, although the medical record should clearly differentiate the E&M service. The CPT codebook states, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.” You can help clarify a separate E&M service by separating the E&M documentation from any other same-day procedure, for example by using a different sheet of paper or a different section of the electronic health record.
Example 1: A patient requires stitches to her knee after falling while running. The patient reports becoming nauseated and dizzy before the fall. In addition to suturing the knee wound, the physician evaluates the reason for the patient’s dizziness, ordering lab tests and a head CT. In this case, the procedure led to a significant and separately identifiable E&M (use modifier 25).
Example 2: A patient presents with a pressure ulcer on his lower back. The physician evaluates the sore, which she diagnoses as stage 3, and debrides the lesion. In this case, only after completing the E&M portion of the visit did physicians make a decision to perform the procedure. The E&M visit (use modifier 25) led to a decision for significant and separately identifiable procedure.
- In some cases, it is appropriate to bill for two E&M services on the same day, if one is preventive and the other problem-focused, or medically necessary. For example, Medicare specifically says it will pay for a significant, separately identifiable medically necessary E&M service (CPT codes 99201-99215) billed the same time as the Medicare Initial Preventive Physical Examination when billed with modifier 25 if that portion of the visit is “medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.”
- A second diagnosis code alone doesn’t automatically qualify an E&M service for a modifier 25. If the new problem needs only a cursory review, it would not qualify. Also, do not report a separate E&M service for a planned procedure. If a patient comes in for a cardiovascular stress test, any history and exam the physician completes related to the stress test is part of the procedure, not a separate E&M.
To decide if an E&M service is separately reportable with modifier 25, AAPC suggests: “Ask yourself, ‘Can I pick out from the documentation a clear history, exam, and [medical decisionmaking] apart from any other procedures the physician performs on the same day?’ If so, you’ve probably got a billable service with modifier 25.”
Here is guidance from payers:
Have coding or billing questions? Contact TMA’s certified coders at (800) 880-1300, ext. 1414, or paymentadvocacy[at]texmed[dot]org for answers. If you’d like coding training, or a review of your coding practices, contact TMA Practice Consulting for information at (800) 523-8776 or practice.consulting[at]texmed[dot]org.
Published Oct. 27, 2015
TMA Practice E-Tips main page
Last Updated On
June 03, 2016