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Pediatric Coding Alert

6 Suggestions for Foolproof Modifier -25 Coding

Published on Fri Jan 02, 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 is to clean up and clarify claims before they go out, so you can avoid the hassle of appeals. When coding with modifier -25, keep these guidelines in mind, says Richard H. Tuck, MD, FAAP, medical director of Quality Care Partners in Zanesville, Ohio:
  
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 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 or laboratory tests. 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, please 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 make sure that all of the exam elements are documented and that the E/M service's diagnosis code reflects medical necessity.
 
For example, if a child reports for repair of a broken nose and the doctor performs a separate E/M exam to check for other head trauma, make your notes on the two services separate and very detailed.
 
5. Don't append modifier -25 for minor-procedure sedation. When a pediatrician administers sedation prior to a scheduled minor procedure, the sedation 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, contact a representative  with the specific insurance carrier and ask for an explanation for refusal of payment.

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