ED Coding and Reimbursement Alert

Auditors could get interested if you misuse this modifier.

Knowing when to append a modifier can be tricky, but many coders will tell you that one of the most misunderstood is modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

If you count yourself in that confused group, use these four criteria to determine whether modifier 25 is right for your next coding assignment.

1. Modifier 25 is for E/M only

You can only consider reporting modifier 25 when coding an E/M service, says Janet Palazzo, CPC, of Regional Otolaryngology in Cherry Hill, N.J. If the procedures you're reporting don't fall under E/M services, it's possible the encounter qualifies for another modifier instead.

How it works: You would use modifier 25 to indicate you have documentation that supports an E/M was significant and separately identifiable from the work included in another service or procedure. By contrast, modifier 59 (Distinct procedural service) can be used only to distinguish one non-E/M procedure from another non-E/M procedure.

2. Extent of service makes a difference

CPT's Appendix A states that a significant and separately identifiable service "is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported."

You need to add modifier 25 because some minor procedures (0- and 10-day global procedures) include a small E/M within the value of the minor procedure. Therefore, in order to be paid for an E/M and the minor procedure, you have to tell the payer that the E/M was significant and separately identifiable from the minor procedure When the patient's complaint can stand alone as a billable service, you might be able to use modifier 25. How can you tell?

"Look at the documentation and cross out anything that is directly related to the procedure performed," says Judith L. Blaszczyk RN, CPC, ACS-PM, compliance auditor with ACE consulting in Leawood, Kan. "Look then at the remaining documentation to determine if it is indeed significant, separately identifiable and medically necessary," she adds.

Example: For example, a patient presents to the ED with knee pain. The physician performs a full evaluation of the patient including screening for signs or symptoms of a systemic arthritic syndrome, checking for gout, and evaluating the remainder of the musculoskeletal system and other areas. and as a result of the complete history, exam and medical decision making, plans to perform a steroid injection. Since this E/M was distinct from the minor procedure, a 25 modifier would be appropriate on the E/M service. Ultimately the physician diagnoses the patient with a joint effusion and bursitis.

Pointer: Though you do not have to have different diagnoses to compliantly report modifier 25 with an E/M code, you should link the different diagnoses to the appropriate CPT codes when applicable. In the above example, you should link 719.06 Effusion of joint, lower leg for the knee pain.) to the E/M code as the primary diagnosis. Then, link 727.2 (Specific bursitides often of occupational origin) as the primary diagnosis code for the knee injection.

3. Global period length offers clues

Another common point of confusion is between 25 and modifier 57 (Decision for surgery). You should typically use modifier 25 with procedures that have a 0- or 10-day global period. These kinds of procedures are what Medicare defines as "minor." In contrast, you'll use modifier 57 for procedures with a 90-day global period.

Do this for 25: Your modifier 25 claims should meet all of the following criteria:

• The E/M occurs on the same day as the surgical procedure
• The procedure following the E/M is minor (has a O- or 10-day global period) The E/M service is both significant and separately identifiable from any inherent E/M component that the procedure involves
• The same physician (or one with the same tax ID) provides the E/M service and the subsequent procedure.

Follow 57 guidelines: Use modifier 57 if the claim meets all of the following criteria:

The E/M occurs on the same day of or the day before the surgical procedure

The E/M service directly prompted the surgeon's decision to perform surgery

The surgical procedure following the E/M has a 90-day global period

The same surgeon (or another surgeon with the same tax ID) provided the E/M service and the surgical procedure.

Because modifier 57 claims involve an E/M service that results in a decision for surgery, you would generally expect to see the same diagnosis code for both the E/M and the surgical procedure. The surgeon would most likely not make a decision for surgery based on a significant problem unrelated to the procedure.

Example: A 47 year old female slipped on the ice, landing awkwardly on her left lower leg. She is in considerable pain and unable to bear any weight on that leg. Examination suggests a tibial shaft fracture, which is confirmed with X-rays.

The physician reduces the fracture and applies a cast. Because the E/M service was the decision for the surgical procedure, append modifier 57 to the E/M code, along with 27752 (Closed treatment of tibial shaft fracture [with or without fibular fracture; with manipulation, with or without skeletal traction]).

4. Avoid scrutiny, don't overuse 25

Some coders view modifier 25 as a "magic bullet," says Blaszczyk. She has heard from some coders that "always add a 25 modifier to their E/Ms done on the same day as a procedure because that is the only way they can get them paid," Blaszczyk adds.

That kind of coding is improper and incorrect, says Palazzo. "Any practice that applies modifier 25 indiscriminately to their E/Ms will be an outlier to other practices in the volume of claims billed with modifier 25 and will be sending up red flags," says Blaszczyk.