Neurology & Pain Management Coding Alert

Avoid overusing this modifier and soliciting an audit with four tips.

If you find yourself especially overwhelmed and confused by modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), you're not alone. Luckily, you can use these four criteria to determine whether modifier 25 is right for your neurology coding assignment.

1. Modifier 25 is for E/M Only

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.

How it works: You would use modifier 25 to indicate you have documentation that supports an E/M was significant and separately identifiable from the work included in another service or procedure. By contrast, modifier 59 (Distinct procedural service) can be used only to distinguish one procedure from another procedure.

2. Extent of Service Makes a Difference

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."

When the patient's complaint can stand alone as a billable service, you might be able to use modifier 25. How can you tell? "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 consulting in Leawood, Kan. "Look then at the remaining documentation to determine if it is indeed significant, separately identifiable and medically necessary," she adds.

Example: Your neurologist sees a patient for management of her Alzheimer's disease, and at the same visit 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 postprocedure work associated with the injection procedure.

Pointer: Though you do not have to have different diagnoses to compliantly report modifier 25 with an E/M code, you should link the different diagnoses to the appropriate CPT codes when applicable. In the above example, you should link 331.0 (Alzheimer's disease) to the E/M code as the primary diagnosis. Then, link 729.1 (Myalgia and myositis unspecified) as the primary diagnosis code for the injection procedure.

3. Global Period Length Offers Clues

Another common point of confusion is between 25 and modifier 57 (Decision for surgery). You should only use modifier 25 with procedures that have a 0- or 10-day global period. 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, says Rena G. Hall, CPC, a coder and auditor with KC Neurosurgery Group in Kansas City, Mo. 4. Avoid Scrutiny, Don't Overuse 25 Some coders view modifier 25 as a "magic bullet," says Blaszczyk.

She has heard from some coders that "always add a 25 modifier to their E/Ms done on the same day as a procedure because that is the only way they can get them paid," Blaszczyk adds. Don't fall into that trap, she warns. "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."