Oncology & Hematology Coding Alert

Question: We are not sure when we can append modifier 25. Could you please explain this?

South Carolina Subscriber

Answer: 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, so if you ever have doubts about whether you are properly using it in the future, make sure you follow these rules:

• Only append modifier 25 to evaluation and management (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).
• You may use modifier 25 only when your provider’s documentation proves he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the original procedure. Your physician must include a separate History, Examination, and Medical-decision making for the E/M service in his documentation.
• The E/M service must occur on the same calendar day as the original procedure, for the same patient.
• You do not necessarily need two different diagnosis codes to append modifier 25. While different diagnoses help show the separate nature of the E/M service, they are not required for using modifier 25.  
• The procedure following the E/M would be a minor procedure, meaning it has a zero or 10-day global period. For 90-day procedures, you would instead use modifier 57 (Decision for surgery) on the E/M service if it occurs the day of or the day before the major surgical procedure. But keep in mind Medicare always considers the decision to perform minor surgery as part of routine surgical care so be sure the E/M reflects for more than this and informed consent.