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Pediatric Coding Alert

6 Suggestions for Foolproof Modifier -25 Coding

Published on Thu Jan 01, 2004

Who knew that one little modifier could cause so many headaches? Put modifier -25 on your claims, and you'll have payers up in arms. But defend your modifier -25 claims right from the start and you can avoid those denials.
 
The easiest way to report and get paid for modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is to be proactive. Clean up and clarify these claims before they go out, and you're more likely to get paid without any hassle. When coding with modifier -25, keep these guidelines in mind:
 
1. Append modifier -25 only to E/M services. Do not use it on any procedure codes. You should use modifier -25 with an E/M service that's performed on the same day by the same physician as another procedure or service. Many coders understand this concept, but in the flurry of getting claims out, they accidentally append the modifier to a procedure code.
 
2. Don't append modifier -25 to E/M codes when the only other codes for that claim are for ancillary services, like x-rays and laboratory codes. Also, some carriers restrict the use of modifier -25 to an E/M coded with a surgical service. Because there is some variation in this area among payers, consult your local carrier for its specific policy.
 
3. Include separate documentation for both your E/M and procedure codes. You need to show medical necessity that justifies reporting both the E/M code and the procedure code(s). So, you must have separate documentation for each service.
 
4. If you bundle your procedure note into the examination component of the E/M documentation or even tag it in the decision-making component, you could be losing legitimate revenue. Remember that when using modifier -25, you should have all of the elements of the exam documented, and the E/M service's diagnosis code must reflect medical necessity.
 
5. Don't append modifier -25 for minor-procedure sedation. The examination that is performed and needed to administer conscious sedation prior to a scheduled minor procedure is not a "significant, separately identifiable E/M service." It is a component of the minor procedure and is not separately billable, even with modifier -25.
 
6. If you're still not getting paid, contact the representative for the relevant payer. Sometimes, problems arise when trying to get claims paid using modifier -25. When this occurs, check with the specific insurance carrier for an explanation for refusal of payment. If this doesn't work, contact your billers and get your information ready for an appeal. When billers take over, they often can reverse modifier -25 denials.

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