Medicare Compliance & Reimbursement

Do your modifier 25 skills measure up to CMS's requirements? You'll find out the answers to our quiz (questions on page 44) below to determine where you excelled.

Answer 1: Medicare does not require that you document separate notes to justify using modifier 25. "What is necessary is that all of the elements of an office encounter are met for the level billed and that the visit does not totally relate to the service or procedure that is performed in the office," says Daniel J. Rogers, practice manager with Gulf South Urology in Biloxi, Miss.

For instance, if a male patient presented to a urology clinic for evaluation of urinary frequency and strength of stream while voiding, it would be common for the physician to do a post-void residual study and a voiding flow study, neither of which would require a modifier 25 for the visit, Rogers says.

However, Rogers says, if the patient added that he had hematuria and if the results of the diagnostics indicated, the physician might opt to do a cystoscopy which was not planned or expected to go with the entire E/M visit. "This is an additional service based on the findings of a complete E/M visit which could stand alone," thus warranting use of modifier 25.

When the patient presents with only one condition, it can be tricky to bill the E/M and procedure with modifier 25, says Aman Kaur with Parsons Medical Center, Inc. in Brandon, Fla. "But documentation is the key" to getting both services paid, Kaur says.

Example: A diabetic patient presents with a painful left foot, and upon examination, the physician finds an abscess there and makes a decision to do an incision and drainage. The physician still did an extensive foot and leg exam on both sides and review of system since the patient is diabetic. The visit should qualify for billing both the I&D procedure and the E/M with modifier 25 appended, Kaur says.

"The bottom line is that the documentation will qualify for modifier 25 criteria if you can draw a separate line between the E/M service and the procedure," Kaur says.

Answer 2: You may report a covered E/M visit and Q0091 (Screening papanicolaou smear...) for the same date of service if the E/M visit is for a separately identifiable service.

"The same physician may report a covered E/M visit and code Q0091 for the same date of service if the E/M visit is for a separately identifiable service," according to the Medicare Preventive Services Guide. "In this case, the modifier 25 must be reported with the E/M service and the medical records must clearly document the E/M service reported. Both procedure codes are to be shown as separate line items on the claim."

To read the Medicare Preventive Service Guide, visit www.cms.hhs.gov/mlnproducts/downloads/psguid.pdf.

Answer 3: Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the office visit. Since the patient's problem prompted the doctor to perform the trigger point injection, you should append modifier 25 to 99213.

In addition, you'll report 20552 to represent the physician's work performing the trigger point injection.

Answer 4: In some cases, an appeal might be necessary. If you are confident that you used modifier 25 appropriately for a significant, separately identifiable E/M service on the same date as a procedure, you should appeal to your carrier.