Modifier -25 Could Be Crucial Under APCs

For years, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) has been a physician-side issue only. This modifier allows doctors to bill evaluation and management (E/M) services in conjunction with procedures under many circumstances, and it has confused coders since it was created in 1992. But with the advent of ambulatory payment classifications (APCs) on Aug. 1, hospitals and outpatient treatment centers will be using it as well.

CPTs 1999 clarification of modifier -25 added language that makes it much easier for coders to understand when and how to append the modifier, but some questions about use and reimbursement still remain.

Mason Smith, MD, FACEP, president of Lynx Medical Systems, a coding and documentation consulting firm in Bellevue, Wash., says that both coders and payers still have a broad misconception that any time a procedure is done, no visit code is payable. Modifier -25 indicates to Medicare and other payers who follow it that a surgical procedure performed on the same day was significantly different than the procedure that the -25 modifier is appended to. Simply put, if I use the -25 modifier, I want to be paid for the evaluation and management portion. If I leave it off, I dont want to be paid.

That sounds like a simple issue, but years of misunderstanding and entrenched ideas complicate the matter.

Reimbursement when using the modifier is also problematic at times, according to Diane Krier-Morrow, CCS-P, MBA, MPH, manager of the Chicago staff for the socioeconomic affairs department of the American College of Surgeons. Many payers still deny E/M services because they dont recognize modifier -25.

Using the Modifier

Modifier -25 is a chance to bring more revenue to the hospital. Say I have a level-four evaluation of an elderly person with a head injury, Smith says. Payment for that visit will be $155 unadjusted. The laceration repair, 12013 (simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm), will pay $118 unadjusted. So if a -25 modifier is placed on the 99284 (emergency department visit for the evaluation and management of a patient, which requires a detailed history and examination and medical decision-making of moderate complexity), then the hospital will receive an extra $155. Thats for the hospital visit service. If the hospital does not put a -25 modifier on its UB-92 bill, then the visit will not be paid, only the laceration repair.

This coding could cause problems for facilities used to cost-based reimbursement. Smith maintains that 1,800 American hospitals used 99201, the lowest level new-patient office visit code, for every emergency department (ED) visit. After Aug. 1, They will have [...]

- Published on 2000-07-01