Neurology & Pain Management Coding Alert

Mythbusters:

Make Modifier 25 Concerns Disappear With These Tips

Published on Mon Jul 17, 2023

Don’t let work, money go to waste.

Getting paid for modifier 25 claims has often been tricky, but these payments are vital to get each and every PM and neurology practice.

Why? If you’re not getting paid what you deserve to due to 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) issues, you’re leaving money on the table. And the work of the provider to perform that significant, separately identifiable service will all have been for naught.

Don’t let that happen; check out these pointers on earning the payment your providers deserve.

Myth 1: Minor Procedure + Minor E/M = Payment With Modifier 25

All billable minor procedures (0-day or 10-day global period) already include an inherent small evaluation and management (E/M) component to gauge the patient’s overall health and the medical appropriateness of the service. Since the decision to perform a minor procedure is included in the payment — the relative value units (RVUs) include pre-service work, intraservice time, and postprocedure time — an E/M service should not be reported separately.

When your providers address an additional problem at the time of another service/procedure and the patient’s condition requires work above and beyond the other service provided or the usual care associated with the procedure performed, you should report the separate E/M with modifier 25 appended to get paid for both services.

Before you go reaching for modifier 25, make sure you’re using it because a minor procedure or other service and a separate and significant E/M service were performed:

On the same patient;
By the same physician; and
On the same date.

The key is recognizing when the additional work is “significant” and, therefore, additionally billable.

Myth 2: Different Dx Codes Are Necessary

Different diagnosis codes are unnecessary; in some cases, the diagnosis code for the E/M and procedure codes will be the same. Claim success hinges on the E/M service being separate and significant; the documentation must substantiate this, and the physician’s work must be medically necessary.

Typically, if the E/M service is unrelated to the minor procedure (i.e., for a different concern/complaint) or occurs due to exacerbation of an existing condition or other change in the patient’s status, the E/M service may be reported separately if it is independently supported by documentation.

Myth 3: You Need 2 Notes

While you don’t need separate notes, physically separating the documentation for the E/M service from documentation for the other same-day procedure or service may help. What is necessary is having a medical record that demonstrates the necessity of and justification for the services performed. Payment hinges on the provider appropriately and sufficiently documenting both the medically necessary E/M service and the minor procedure/other service in the patient’s office note to support the claim for these services.

Tip: Make sure your providers show their extra cognitive work, as it will serve a critical role when the payer reviews the claim.