4 Questions to Ask Yourself About Modifier -25

If you want to recoup reimbursement for your modifier -25 claims, make sure that you can separately identify your endocrinologist's E/M services from other procedures he or she performed on the same day.

Here are four easy questions to ask yourself - with answers from the experts - to help guide you on the road to hassle-free 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).
1. Does Your E/M Service Stand Alone?
CMS specifies that all procedures have an E/M component. Private payers also assume that there's an inherent E/M visit built into the reimbursement for procedure codes, because most physicians do a certain amount of "visiting" with the patient before any procedure. This is where you need to be careful of overuse. Don't append modifier -25 just because your endocrinologist spoke with the patient before doing the procedure.

To get paid using modifier -25, the E/M service needs to be completely separate and identifiable from the procedure. For example, a woman who has had several miscarriages visits a reproductive endocrinologist (RE) for an endometrial biopsy (58100, Endometrial sampling with or without endocervical sampling, without cervical dilation, any method) to assess her uterine lining. During the visit the woman voices concern about a lump in her breast, prompting the RE to also perform a problem-focused exam of her breast, with history and medical decision-making. You should report 58100, as well as E/M code 99213 (Established patient, office or other outpatient visit) with modifier -25 appended to the E/M, says a coding expert from an endocrinology practice in the Atlanta area.

The separate service or procedure may stem from a problem brought up by the patient or the doctor. Sometimes an easy way to tell that there are two separate services is if one service is unrelated to the reason why the patient was scheduled. For instance, in the example above, the woman was scheduled for an endometrial biopsy but also received a problem-focused exam of her breast that was totally unrelated to the procedure she was scheduled for.

Smart idea: When asking yourself if a procedure stands alone, separate the E/M notes from the procedure documentation in your medical record. If a reviewer could look at your medical notes and clearly see that the physician completed two separate and independently identifiable services, you can append modifier -25.
2. Do You Need Additional Diagnoses?
You may think that in order for an E/M service to be separately identifiable, the service must have a separate diagnosis. Not true. CPT states that an E/M service may be prompted by a symptom or condition [...]

- Published on 2004-02-10