Medicare Compliance & Reimbursement

Tip: Documentation must show medical necessity.

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 one of the most misunderstood modifiers and lands many a practice in the denial zone. And since Medicare claims reviews are on the rise, you can’t be too careful when it comes to compliance. Take a minute to register these four quick rules on your road to coding success.

Follow these rules, to combat modifier 25 woes:

• Rule 1: You can only append modifier 25 to E/M service codes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components ...) through 99499 (Unlisted evaluation and management service).
• Rule 2: You may use modifier 25 only when a provider’s documentation proves that he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the original procedure. The physician must include a separate history, examination, and medical decision making for the E/M service in his documentation.
• Rule 3: The E/M service must occur on the same calendar day as the original procedure for the same patient.
• Rule 4: The procedure following the E/M would be a minor procedure, meaning that it has a zero or 10-day global period.