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Anesthesia Coding Alert

Modifier Heads-Up:

There Are New Rules for Reporting Modifier 25: Here's What You Need to Know

Published on Wed Aug 16, 2006

CMS clarifies when -- and how -- to use it 

New guidelines regarding modifier 25 went into effect Aug. 20. If your physicians sometimes provide E/M services on the same day as other care, pay attention to the CMS clarification:

"This revision clarifies the existing payment policy on the correct use and documentation of CPT modifier 25 [Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service] to identify a significant, separately identifiable evaluation and management (E/M) service. This modifier shall be used when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global fee period performed on the same day as the E/M service."

What it means: The difference in guidelines -- and the determination of when to report modifier 25 -- lies in the procedure's global period. Instead of automatically appending modifier 25 to additional services, you only use modifier 25 when the extra procedure has a global period. If the procedure does not have a global period, you report it along with the E/M service but do not append modifier 25.

Example: A patient visits your pain management specialist for a routine medication review related to her low back pain. During her visit, your physician decides to administer a trigger point injection to relieve her pain. You'll code the visit with 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) and 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]).

Because the trigger point injection does have a global period (although it's only one day), you'll append modifier 25 to the E/M code (99213).

The update is from Transmittal 954 of the CMS Manual System (CR 5025), dated May 19. To read the complete transmittal, log on to www.cms.hhs.gov/transmittals/downloads/R954CP.pdf.

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