# "Teaching modifier 25 to non-coders



## anastasia213 (Dec 12, 2012)

I am new to my teaching role and I have been tasked with presenting and "teaching" the appropriate use of modifier -25 to our charge entry staff. The majority of these folks are not certified coders, some have VERY little coding knowledge and they have been taught some ugly habits ("to make it easier for them") that I need to break. 

Does anyone know of a good (and credible) source to find easy to understand information on modifier 25? Something that might have examples, etc??? I can come up with something myself, but I am afraid it may be good in my head, but not understood by all. 


Any suggestions would be helpful!


Thanks, 
Stacey


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## Lynda Wetter (Dec 12, 2012)

Links are below...

25 Modifier
Significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

The following conditions must be met to report modifier 25:

*  The patient's condition required a significant, identifiable E/M service
above and beyond the other service provided or services beyond the usual
preoperative and postoperative care associated with the procedure that was
performed.

*  These circumstances may be reported by adding the 25 modifier to the
appropriate level of the E/M service.

In the conditions above, the bold areas indicate the key phrases for the proper use of the modifier.


In the conditions above, the bold areas indicate the key phrases for the proper use of  the modifier.

1. The phrase, “the patient's condition required” is extremely important. In other words, it was medically necessary for the patient to have these extra services on the same day that another procedure or service was performed.

2. The phrase, “a significant, separately identifiable E/M service above and beyond” the other service provided indicates that this extra service was clearly different from the other procedure or service that was performed.

3. The phrase, “services beyond the usual preoperative and postoperative care”
associated with the procedure emphasizes the fact that all procedures as defined in the Resource-Based Relative Value Scale (RBRVS) system of reimbursement that Medicare uses include a certain amount of preoperative and postoperative care in the reimbursement package. The 25 modifier should be used if extra work beyond the usual is performed. A good standard for judging whether the 25 modifier should be used is: If a physician in the same specialty area would agree after reading the clinical record that extra preoperative and/or postoperative work beyond what is usually performed with that service was performed, then it is proper to use the 25 modifier to indicate that extra work. To document the extra work performed, the clinical record should clearly indicate that extra or unusual work.

Primary considerations for modifier 25 usages are:

 Why is the physician seeing the patient?
o If the patient exhibits symptoms from which the physician diagnoses the
condition and begins treatment by performing a minor procedure or an
endoscopy on that same day, modifier 25 should be added to the correct level
of E/M service.

o If the patient is present for the minor procedure or endoscopy only, modifier
25 does not apply.

o If the E/M service was to familiarize the patient with the minor procedure or
endoscopy immediately before the procedure, modifier 25 does not apply.

*  If the E/M service is related to the decision to perform a major procedure (90-day global), modifier 25 is not appropriate. The correct modifier is modifier 57, decision for surgery.

*  When determining the level of visit to bill when modifier 25 is used, physicians
should consider only the content and time associated with the separate E/M
service, not the content or time of the procedure. 


http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM5025.pdf




Really you can google it and come up with ALLOT of helpful sites and information to fuel your teaching session!!!


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## anastasia213 (Dec 13, 2012)

Thank you for the input, this will be a tremendous help. I do use google, my only concern is being new to some of this stuff, I want to be sure that what I am using is from a reputable source. 


Thanks again for your help!


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## Lunap99 (Nov 15, 2021)

I'm a bit confused on one point stated above.
"If the patient exhibits symptoms from which the physician diagnoses the condition and begins treatment by performing a minor procedure or an endoscopy on that same day, modifier 25 should be added to the correct level of E/M service."
The patient presents for a sprained toe that was previously diagnosed and supposedly treated by another provider in a different state. He says that it is still painful. My provider took some history, did a lower extremity exam, took x-rays of the one foot.  She determined the patient has capsulitis, recommends appropriate shoes and orthotics and performs an injection to the affected joint.
By the statement above, I would be able to bill a separate E/M but there is only the one diagnosis. So how can I determine if the E/M is actually appropriate?


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## TThivierge (Nov 16, 2021)

Hi There
This is late but I'd goggle some coding journals such as Just Coding  or For The Record or Healthcare Billing ..should have some article can print off and discuss it. Or check out the NCCI website.  Also if skin lesions or trigger point injection procedure in which pt. arrive for just this procedure and  that is only thing done do not put modifier 25 on it...will not pay. Insurance and CMS feel if this is advance appointment no modifier 25 whereas if incidental  to the main medical visit visit then add modifier 25.
Luna I d bill the Xray and visit with  modifier 25. I d add the dx pain code M25 or M79 per limb and Capsulitis dx if no Excludes 1 rule is on it. Add history code of Z87 block past multiskeletal problem  before too
I hope this data helps you
Lady T


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## Lunap99 (Nov 17, 2021)

To further clarify, if the chief complaint is, for example, "toenail fungus, nail care". This was a new patient , provider did new patient history and an exam of the feet then debrided the nails.  The reason for the visit was treatment of nails and the provider treated by debridement so a separate E/M is NOT supported, correct?  
Alternately, if the patient came in with a complaint of "painful toes" or "crusty nails", the provider did that same history and foot exam then determined that there was nail fungus and treated with debridement, a separate E/M would be allowed.  If this is the case, does it still have to meet the criteria that if you remove the nail debridement, what remains still has to support an E/M?


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## Lunap99 (Nov 17, 2021)

This provider sent us this comment " So someone needs to convince me that I can not charge for an E/M on the initial visit as well as charge a procedure. I have historically been told that I can charge an E/M on initial visit (or when it is a new issue for an established pt) in addition to charging for the procedure."
Did the guidelines change with the new E/Ms in 2021?


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