Hone Your Modifier 25 Policy With These Guidelines
Published on Thu Sep 14, 2006
Private payers may drop the modifier requirement forj medicine/service claims
You finally have a fail-safe policy to stop the nagging doubt over whether you should append modifier 25 to the E/M service on a claim that also involves a medicine code. CPT: Many Medicine + E/M Claims Don’t Require 25 When you perform an office visit that is separate and distinct from a medicine service, “the E/M code does not typically require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service),” says Richard H. Tuck, MD, FAAP, a nationally recognized pediatric coding speaker with PrimeCare of Southeastern Ohio. “You will not find any language to that effect in CPT or CPT Assistant .”
But your office may be in the habit of automatically entering 25 on all claims for same-day office visits with associated medicine services. Physicians have been increasingly using modifier 25 because payers have recognized the modifier and paid claims coded in that manner, Tuck says. “Thus, the modifier has become used more frequently than rules necessarily dictate.”
Tuck says the following medicine services are among those that CPT does not require to have modifier 25 on the E/M service code (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient …):
• developmental testing (96110, Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report)
• hearing screening (92551, Screening test, pure tone, air only)
• nebulizer training (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device)
• nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device])
• vision screening (99173, Screening test of visual acuity, quantitative, bilateral). CMS Echoes CPT Policy Recently, the Centers for Medicare & Medicaid Services backed this less-use policy with a much-needed clarification. New guidance: As of Aug. 20, you should only use modifier 25 when the physician provides a significant and separately identifiable E/M service on the same day as a procedure with a global period, says Jim Collins, CPC, CHCC, president of Compliant MD Inc. in Matthews, N.C.
CMS Transmittal 954 states that modifier 25 “shall be used when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global fee period performed [...]
