Medicare Compliance & Reimbursement

Tip: Recognize the differences between modifiers’ 25 and 57.

Most Medicare providers see beneficiaries for E/M visits everyday; however, sometimes those patients also need a procedure during that visit. And with more payers cracking down on modifier 25 claims, it’s critical that you understand exactly how and when to separately report an E/M visit with a procedure.

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) is probably one of the most used modifiers available, but it is also perennially misused and misunderstood. Small wonder, then, that “appropriate use of modifier 25 has often been on the Office of the Inspector General’s [OIG’s] Work Plan,” according to Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

“The OIG reviews use of modifier 25 and may audit organizations that overuse the modifier. This is also true of Medicare Administrative Contractor [MAC] and Recovery Audit Contractor [RAC] audits,” Bucknam cautions. So, we’ve prepared this timely reminder of the correct way to use modifier 25 and added to it some examples of how the modifier should, and should not, not be used.

What, Exactly, Does a Modifier Do?

Before looking at modifier 25’s role in depth, a reminder of the two functions any modifier performs is in order. CPT® defines those functions as:

• Providing “the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code,” and
• Enabling “health care professionals to effectively respond to payment policy requirements established by other entities.”

In other words, modifiers allow you to indicate when circumstances require a provider to change a service or procedure described by a specific CPT® code without changing the underlying code itself. This, in turn, enables payers to determine what the provider did and how, or even if, they should pay for that particular service.

How Is Modifier 25 Misused?

If you read the modifier descriptor closely, you can begin to see some of the problems you can encounter when using it. Simply put, if the procedure or other service is not on the same day, if the E/M service is not significant or separate from the procedure, and if the same physician or qualified healthcare professional (QHP) did not perform both the E/M service and the procedure (or if either service was performed by someone other than a physician or QHP), then you have incorrectly applied the modifier.

Example: Your office schedules a patient for a leg lesion removal, and the provider performs 11401 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm). “Billing a separate E/M service with modifier 25 in this scenario would not be appropriate,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “This is because the lesion removal was the sole reason the patient came to the office. The provider did not perform a significant or separately identifiable E/M service, so you cannot charge for it.”

Caution: Coders often confuse modifier 57 (Decision for surgery) with modifier 25 — which you typically should use only for significant, separately identifiable E/Ms that lead to minor surgical procedures (global periods of 0 or 10 days).

In a perfect world, the only mistake you could make when choosing between 25 and 57 is miscounting the global days. Unfortunately, payer differences have made the distinction between 25 and 57 more nebulous, warns Sharon Richardson, RN, consultant for Brault in San Dimas, California.

“Whether a 57 or 25 modifier is used on the E/M service is dependent on the payer,” she explains. “Medicare used to always require a 57 modifier when the decision to ‘do surgery’ was made at the time the patient was initially seen and the procedure had a 90-day global period; but that is no longer the case.”

Now, Richardson continues, some MACs still honor this modifier 57 coding convention. However, others now require a 25 modifier instead of 57.

The modifier 25/57 waters are getting muddier with time, so “it really is hit and miss,” and can change by payer, or by year, Richardson says. Your best defense against miscoding is to “know your payers and their requirements.”

How Should I Use Modifier 25?

If, on close examination of a provider’s notes, you can separate out a history, exam, and/or medical decision making (MDM) that add up to a specific E/M level, then you likely have a case for appending the modifier to the E/M service in question. You should note, too, that you don’t necessarily have to have a separate diagnosis to justify the E/M.

Consider this scenario: An established patient presents with a 2 cm laceration to the forehead after falling from her bike just before arriving at your office. You review her vaccination record to make sure her tetanus shot is up to date, check the patient for headaches and nausea, palpitate and inspect the area around the laceration for any other deformity and, in the absence of any other problems, perform 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less), giving the patient instructions to keep the bandage clean and dry and return in 10 days.

“The clear extra and separate work the provider performs to identify the patient’s immunization status, possibility of a fracture, and concerns for a possible concussion, even though the other conditions are ruled out, documents that the physician provided separate work in addition to the laceration repair,” says Bucknam. “This means you can bill an E/M service separately using modifier 25.”

Coding alert: “Contrast this with a note that says, ‘the patient presents with a laceration on the forehead, the wound is cleaned and examined, and five stitches are applied to close the wound.’ You would not be able bill for the E/M service in this case, not just because the length of the note but because no work is documented above and beyond the work involved in the procedure itself,” Bucknam reasons.

The Bottom Line

Before you submit any more claims featuring modifier 25, “you should ask yourself the four following questions,” says Falbo.

• Was the procedure or service unscheduled?
• Did the E/M service uncover signs and symptoms in the patient that the provider must address with a procedure or service?
• Did the provider address more than one diagnosis?
• Did the provider perform work that went above and beyond normal preoperative and postoperative work?

“Answer ‘yes’ to any of them, and there’s a good chance that an E/M service with modifier 25 appended will be seen as medically necessary, providing you have the documentation to support it,” Falbo concludes.