ED Coding and Reimbursement Alert

Question: We frequently submit claims with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended, but we've heard that using this modifier sends out red flags with the insurer. Is this true, and if not, what do Medicare payers look for when they're reviewing this modifier?

Codify Subscriber

Answer: It can be disconcerting to report a code and wonder what happens to it after you've submitted it, but remember that you have no need to worry about using a modifier if you're appending it correctly. Insurers want to be sure you're coding properly, but if you are, they shouldn't take issue with you.

Part B MAC Novitas Solutions answers a similar question on its "Evaluation and Management Services FAQs," which was last updated on April 18, 2017.

When asked how the insurer reviews E/M claims billed with modifier 25, Novitas responded, "In the review of E/M services billed with the 25 modifier, Novitas Solutions will first identify within the medical records the documentation specific to the procedure or service performed on that date of service. Next, we consider the additional documentation separate from the documentation specific to the procedure or service to determine:

• If there is a significant, separately identifiable E/M service that was rendered and documented, and
• If the required components of the E/M service are supported as 'reasonable and necessary' per Social Security Act, Section 1862(a)(1)(A), and
• What level of care is supported by the documentation?"

Therefore, as long as you can demonstrate a significant, separately identifiable E/M service based on the documentation, the service was reasonable and necessary, and you billed the accurate level of care, you should feel confident in appending modifier 25 to your E/M codes. For example, if the evaluation of the patient's problem resulted in the decision to perform a procedure that day, this would constitute a separately identifiable E/M service and should pass review if documented appropriately.