Oncology & Hematology Coding Alert

So, to help you avoid intrusive and painful reviews, here are three rules to remember before employing one of the most used — and misused — modifiers in coding.

Rule 1: 25 Means Separate and Same Day

The key to using modifier 25 correctly is to read the modifier’s descriptor closely and carefully. Simply put, you have incorrectly applied the modifier:

• If an evaluation and management (E/M) service is not performed on the same day as another procedure or service
• If the E/M service is not significant or separate from the other procedure or service
• 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)

Example: An established patient presents for a routine follow-up after a series of chemo treatments. Your provider reviews the history of the patient’s current illness, examines the patient, and orders lab work to evaluate the effect of the chemo. While the provider is examining the patient, they notice a 0.75 cm melanoma on the patient’s face. Fearing the lesion may be malignant, the provider removes it and sends it to the lab for biopsy. The report comes back positive, so you code 11641 (Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm) for the procedure, and 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making) for the follow-up E/M, appending modifier 25 to the 99213.

In this situation, the provider performed significant, extra, and separate work in the exam and history for the follow-up in addition to the lesion removal. This means you can bill an E/M service separately using modifier 25.

Contrast this with a note that says, “the patient presents with a suspected melanoma on the face, the lesion is removed and sent to pathology, and stiches are applied to close the wound.” In this case, you would not be able bill for the E/M service because no work is documented above and beyond the work involved in the procedure itself.

Coding caution: In general, you should also only use modifier 25 on E/M services performed in conjunction with minor procedures that have a 0- or 10-day global period. Procedures with a 90-day global period will typically take modifier 57 (Decision for surgery). The global period for 11641 is 10 days, so 25 would be the correct modifier to append to the E/M in this case.

And, as modifier 25 is for a separate and significant E/M, you should append it to the E/M code and not the additional same-day procedure code.

Rule 2: Look for Significant Additional Services and Dx

If your provider’s visit documentation describes more than the pre- and post-work for the procedure, there is a potential for reporting a significant and separate E/M.

For example, additional work ups such as labs or diagnostic tests, X-rays, studies, or even referrals to another specialist, providing they are unrelated to the procedure, will build a strong case for an E/M code plus modifier25.

Similarly, if the provider indicates the encounter involved discussing a condition or existing problem that is unrelated to the condition the current procedure is treating, that will also build a strong case for attaching modifier 25. A new diagnosis, separate from any diagnosis related to the procedure, or a new treatment plan for an existing diagnosis often supports using modifier 25; however, a new diagnosis is not required to justify a significant and separate E/M service. Importantly, you should make sure the provider’s assessment, if performed, is noted in the medical record, and the new diagnosis, if assigned, is included on the claim form.

Rule 3: Don’t Use 25 With Scheduled Procedures

Let’s suppose your office schedules a patient for the same lesion removal procedure. At the appointment, the provider solely performs the procedure; they perform no additional history or exam, and they exercise no medical decision making (MDM). In this case, “billing a separate E/M service with modifier 25 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.”

The Bottom Line: Ask Yourself These Questions Before Appending 25

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 for a same-day procedure?

“Answer ‘yes’ to any of them, 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.