Medicare Compliance & Reimbursement

Your patient may require a service and an E/M visit on the same date, but if you aren't applying modifier 25 properly, you might have to kiss reimbursement goodbye.

Starting point: Remember that you can only consider reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when coding an E/M service with a procedure. If your physician performs two procedures, neither of which is an E/M service, check whether the encounter qualifies for modifier 59 (Distinct procedural service) instead.

Do not add a modifier 25 just because the procedure was not scheduled prior to the visit. If the E/M service your physician performed is only the minor E/M associated with the procedure, you cannot add modifier 25.

As CPT's Appendix A explains, 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."

Although this description seems crystal clear to some, it muddies the waters even further for coders who are  looking for more specific information.Determine how well you know the modifier 25 rules by answering these four quick quiz questions:

Question 1: Is it necessary to write separate notes for my E/M visit and my procedural service to warrant billing modifier 25, or will one set of documentation be sufficient to substantiate my claim?

Question 2: Our physician recently evaluated gastrointestinal upset during a well-woman visit. Will Medicare accept an E/M code along with the screening code for this service? Is modifier 25 necessary, or can we go without it for this visit?

Question 3: My physician saw a patient in his office for a level-three new patient visit. He performed a singletrigger point injection (20552) during the visit. Which codes and modifiers do we need to report for this visit and procedure?

Question 4: If we feel like our carrier wrongly denied our modifier 25 claims, can we appeal?