Are your claims with evaluation and management (E&M) codes being denied when billed with modifier 25?
TMA receives many inquiries from practices about such denials. Not only are some insurance carriers now requiring practices to submit medical records with a modifier 25, but also they often then deny the claim, saying documentation doesn’t support the use of modifier 25.
Modifier 25 denotes a significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of a procedure or other service.
All minor procedures (with zero- to 10-day global periods) have an inherent E&M component. The relative value unit associated with the minor procedure includes the decision to perform the procedure, the preservice work, intra-service time, and post-procedure time. Therefore an E&M that only addressed the diagnosis for the minor procedure performed should not be reported separately.
When an E&M bundles with a procedure, modifier 25 will be supported only if the documentation supports the occurrence of a separate E&M, distinct from that minor procedure. Modifier 25 indicates the physician went above and beyond the physician work normally associated with the procedure. This modifier tells the payer the same physician addressed a new or existing problem during the same visit as the minor procedure.
Documentation that supports a separate E&M occurred should be clear and detailed in justifying the stand-alone E&M service in addition to the procedure. While it is not necessary to separate notes, it may be helpful to separate the documentation for the E&M service from documentation for the diagnosis related to the procedure.
- Always append the modifier 25 to the E&M code (reported to the appropriate level), never to the procedure code.
- Don’t report a separate E&M service for a planned procedure.
- If a new problem needs only a cursory review, it would not qualify as a separate E&M service.
For additional tips with a range of examples, take a look at the Novitas Solutions webpage on modifier 25 and Humana’s 12-minute video, which links to a downloadable tip sheet.
If you have a question or concern about a claim using modifier 25, or other claim questions, call TMA’s billing and coding hotline at (512) 370-1414 to speak directly with one of TMA’s certified coders. Visit TMA’s Reimbursement Review and Resolution Services page for more ways to get help with claims.
Last Updated On
July 26, 2022
Originally Published On
July 26, 2022