Pediatric Coding Alert

Question: I’m trying to get away from using modifier 25. Is there a requirement saying that I have to use it when billing a hearing test with office visit?

Vermont Subscriber

Answer: When you bill a hearing test such as 92551 (Screening test, pure tone, air only) along with an E/M service, the Correct Coding Initiative (CCI) does not include an edit saying that these codes are bundled together, so you may not have to append modifier 25 (Significant, separately identifiable evaluation and management [E/M] service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the office visit code (such as 99213).

However, if your payer has a specific requirement stating that the codes are bundled and the payer says that you should use a modifier 25, append it to the office visit code.

Keep in mind: If an audiologist performs the screening, many insurers will require you to report the audiologist’s service under his own provider number and the office visit under the pediatrician’s number. In that case, both services won’t be reported on the same claim anyway.

If your insurer prefers that you append modifier 25 to an E/M code when you bill it with a hearing test, you should append it rather than avoid using it. There is no need to “cut back” on your modifier 25 use if you are utilizing the modifier correctly. When insurers say that they are auditing modifier 25 claims, they are looking for misuse (instances of trying to “game the system” by putting it on codes when they shouldn’t rightfully be billing two procedures separately). However, if your insurer has told you in writing that you should report your E/M with modifier 25 on it when billing with a specific procedure, you should not hesitate to bill this way.