Ophthalmology and Optometry Coding Alert

Question: Have the modifier 25 rules changed now that the E/M guidelines are different? My co-worker says they have, I thought they hadn’t.

Delaware Subscriber

Answer: The rules around modifier 25 haven’t changed, but in some ways, the way you apply this modifier are different than they were in the past.

Flash back to five years ago: You wanted to append 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) to an E/M code to demonstrate that you performed a significant, separately identifiable E/M service in addition to a procedure. At that point, you were probably sure to include a sufficient amount of data in the History and Physical Exam sections of your progress notes so that anyone reviewing them would easily be able to see the separate E/M service you performed in addition to the procedure.

However, the lines of where an E/M service ends and a procedure begins may seem to be more blurred now that E/M codes are selected solely based on time spent or the medical decision making component.

At present with the 2021 guidelines, the only history and physical information that require documentation relating to office-based E/M services are those which are clinically relevant; that is, history and exam play no role in choosing the E/M level. Therefore, to report an E/M plus a procedure, one must perform, and document, enough to satisfy that level of new or established work in addition to that of the procedure.

The documentation must still justify a separate E/M service, whether or not you document the history and physical. Therefore, the most important determination you will need to make before billing for a separate E/M with modifier 25 is deciding whether your provider performed any additional work above and beyond the work involved in the procedure. This means knowing what typical pre- and post-work is included in the procedure code, and reading the progress note carefully to evaluate what should be included in the procedure code and what should be billed separately.