Billing & Reimbursement: Modifier -25 Money: Don't Spend It Before Reading This

Rarer Is Better When Mixing E/M and Procedure Codes

Just because your staff routinely performs preprocedure E/M services doesn't mean you should separately bill for them. And when your fiscal intermediary (FI) denies claims for preoperative E/Ms, experts advise that you keep your desire to resubmit with modifier -25 to yourself.

While there are indeed situations in which billing E/M codes with procedure codes - using modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) - is appropriate, they aren't as common as hospitals presume, says Dave Fee, MBA, product marketing manager at 3M Health Information Systems in Murray, Utah. In the vast majority of cases, CMS rolls the E/M service into the APC for "S" and "T" status procedures, so you can't unbundle the charges.

Select Resubmissions With Care

Because facilities use modifier    -25 so often, overpayments in this area have become a problem because FIs mistakenly reimburse for two visits instead of one. Here's a typical scenario: Your hospital clinic bills an S or T procedure and an E/M service together without modifier -25. The FI's claims computer marks the claim with a message stating that modifier -25 is absent, and sends your claim back. You believe the edit message means you can resubmit the claim exactly as it was but with the addition of -25.

But your FI has a different intention: You should resubmit with modifier -25 only when the situation calls for it. Because the language of modifier -25 says you used a distinct set of resources - different staff, different location, etc. - in addition to the procedure resources, you won't use it often.

Unusual Circumstances Call for -25

Despite FI warnings about overuse of modifier -25, there is one place where you can use it liberally: the emergency department, Fee says. When a patient has an acute condition, he normally requires a full-fledged examination that doesn't solely focus on that condition before the physician can choose the appropriate treatment.

See if you can figure out which of these scenarios calls for billing the E/M service and procedure with modifier -25, and which one requires you to bill for just the procedure.

Scenario 1

One of your physicians is repairing a wound on a diabetic patient, and in the middle of the procedure, the patient becomes dizzy. Your staff takes a blood sample and either tests it or sends it to a lab. They obtain the blood-sugar figures, get the patient food, and tell the attending physician about the problem. Then they document all of these efforts.

Scenario 2

A patient visits a wound-care clinic for the first time and needs a full workup - not just an evaluation [...]

- Published on 2003-08-13