EM Coding Alert

Don’t confuse 25 and 57; look to the global period.

Payers are scrutinizing and denying modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) more than ever before. If you are attaching 25 to a significant portion of your provider’s E/M codes, you are sending up a red flag. Learn how to identify legitimate opportunities for separately identifiable E/M and procedure coding using modifier 25 with these three guidelines.

1. Ensure Your Provider Performed a Separate Service

You should use modifier 25 when your provider’s documentation supports that he performed an E/M service that was significant and separately identifiable from the work included in another service or procedure.

When you’re reviewing your provider’s documentation you need to be able to clearly identify the separate service before you can append modifier 25. “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, Inc. consulting in Overland Park, Kan. “Look then at the remaining documentation to determine if it is indeed significant, separately identifiable and medically necessary,” she adds.

Official guidance: 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.”

“If coders slow down and take the time to read the definition of use of modifier 25 in their CPT® book, we would have fewer errors,” says Jetton Torix, CCS-P, course director of McVey Associates, Inc., medical biller for OMB out of Tulsa, Okla., and consultant in North Port, Fla. “Providers often do not remember that if something has to be done to do the main service, it is considered part of it and not separately billable.”

Remember: You can only consider reporting modifier 25 when coding an E/M service. If the procedures you’re reporting don’t fall under E/M services, it’s possible the encounter qualifies for another modifier instead.

Example: Your provider sees a patient for management of her Alzheimer’s disease, and at the same visit the patient mentions she is also having pain. The doctor performs a single trigger point injection (20552, Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) for myofascial pain. In this case you can report both an office visit code, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) with 20552 by appending modifier 25 to the E/M code, to show the E/M service was separately identifiable from the usual pre- and post-procedure work associated with the injection procedure.

2. Don’t Confuse Modifiers 25 and 57

One of the most common points of confusion is between modifier 25 and modifier 57 (Decision for surgery). You might use either modifier 25 or modifier 57 when your provider performs a procedure and a distinct E/M service for the same patient on the same day.

The quickest distinction is that you would use modifier 25 for a distinct E/M with a minor procedure performed on the same day, and modifier 57 for a distinct E/M with a major procedure performed on the same day.

How it works: You should only use modifier 25 with procedures that have a 0- or 10-day global period, Berman explains. 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. Note, however, that some payers are now requesting 57 on 10-day globals, according to Torix, so check with your individual payers.

Watch out: Some coders view modifier 25 as a “magic bullet” and they always add a 25 modifier to E/Ms done on the same day as a procedure because that is the only way they can get them paid. Don’t fall into that trap. “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,” Blaszczyk says.

3. Stop Omitting 25 Because of Same Dx

Proper modifier 25 use does not require a different diagnosis code. In fact, the presence of different diagnosis codes attached to the E/M and the procedure does not necessarily support a separately reportable E/M service. Your key to separately reporting the E/M service lies in whether your provider performed work beyond what is considered to be part of the procedure.

“The guidelines changed years ago that you do not need to have a different diagnosis to use modifier 25,” Torix says. “But it still seems to be easier to get paid if the diagnoses are different,” she adds.

How it works: When using modifier 25, the diagnosis associated with the E/M service can be the same as the diagnosis associated with the same-day procedure, or the diagnosis associated with the E/M service can be different than the diagnosis associated with the same-day procedure. The proof of separately reportable services is in the documentation of the E/M service.

Go to the source: The information about modifier 25 in the CPT manual clearly indicates that you no longer have to have two different diagnosis codes to use the modifier. The CPT manual states: “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.”