ED Coding and Reimbursement Alert

Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) has caused coders significant problems since it was created in 1992. Even though CPTs 1999 clarification of modifier -25 added language that makes it much easier for coders to understand when and how to append the modifier, some questions about use and reimbursement still remain.

Modifier -25 is used correctly to identify an evaluation and management (E/M) service that is both significant and unrelated to the procedure the physician performed or will perform. Normally, E/M services provided on the same day are included in the procedure, but by attaching modifier -25, the physician overrides the carriers software edit, and he or she likely will be reimbursed for the service.

Mason Smith, MD, FACEP, president of Lynx Medical Systems, a coding and documentation consulting firm in Bellevue, Wash., says 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 third-party payers that a surgical procedure performed on the same day was significantly different from the E/M visit procedure that the -25 modifier is appended to. Simply put, Smith asserts, If I use the -25 modifier, I want to be paid for the visit. If I leave it off, I do not want to be paid. This sounds like a simple issue, but years of misunderstanding and entrenched ideas have complicated the matter.

Reimbursement 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, and many payers still deny E/M services because they do not recognize or understand modifier -25.

Examples of Use and Misuse of Modifier -25

The following is an example of the correct use of modifier -25. A lady falls and strikes her head, sustaining a 4-cm laceration on her face. She goes to the emergency department (ED) for examination of the injury, and the laceration is treated. To bill for the laceration repair, the coder would use 12013 (simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm). Depending on the complexity of the exam, E/M code 99283 (emergency department visit for the evaluation and management of a patient, which requires an expanded problem-focused history and examination, and medical decision-making of moderate complexity) or 99284 (emergency department visit for the evaluation and management of a patient, which requires a detailed history and examination, [...]