When to Use Modifier -25 for Facility Coding

By Caral Edelberg, CPC, CCS-P
President, Medical Management Resources Inc.

The long-awaited guidelines for use of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for facility coding were established with the July 20 release of the Health Care Financing Administration (HCFA) Transmittal A-00-40. But the guidelines do not clearly establish the appropriateness of assigning a level for each emergency department visit when a surgical or diagnostic procedure also is performed.

In its new directive, HCFA outlines that payment for diagnostic (with the exception of pathology and laboratory) and/or therapeutic procedure codes (including 10040-69990, 70010-79999, and 90281-99140) includes taking the patients blood pressure and temperature, asking the patient how he or she feels, and getting the consent form signed.

Because payment for these types of services already is included in the payment for the procedure, you cant bill for an evaluation and management (E/M) service separately. When it is appropriate to report an E/M service in addition to procedures performed on the same date, you must effectively document the key components of an E/M service, including history, examination and medical decision-making.

As a more objective outline for use of modifier -25, HCFA has established:

1. Modifier -25 applies only to E/M service codes, and then only when an E/M service is provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure. In other words, modifier -25 does not apply when no diagnostic medical/surgical and/or therapeutic medical/surgical procedure is performed.

2. The procedure and the E/M service are not required to be provided by the same practitioner for modifier -25 to apply in the facility setting. It is appropriate to append modifier -25 to the qualifying E/M service code regardless of whether the E/M and procedure are provided by the same professional.

3. The diagnosis associated with the E/M service does not need to be different from that for the diagnostic medical/surgical and/or therapeutic medical/surgical procedure.

4. It is appropriate to append modifier -25 to emergency department (ED) codes 99281-99285 when these services lead to a decision to perform a diagnostic medical/surgical and/or therapeutic medical/surgical procedure.

Item 4 above might make it appear that an E/M always would be billed in addition to the procedure when it is performed following the establishment of a diagnosis for the medical problem that necessitates the procedure. For the professional coding of this type of visit, modifier
-57 (decision for surgery) would be used. But the -57 modifier is not recognized for the facility coding performed under the APC payment method.

A review of the HCFA examples that illustrate the use of modifier -25 suggests conservative use, as [...]

- Published on 2000-09-01