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Eli's Rehab Report

Reader Question:

Red Flags on Modifier -25?

Published on Thu Nov 01, 2001

Question: We've been told that it's difficult to get paid for a trigger point injection and a physiatrist's E/M on the same day. We have used modifier -25 to combat this, but we've heard that Medicare "red  flags" people who use too many modifiers. How should we bill this?

Texas Subscriber
 
Answer: Using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to bill for what you can demonstrate to be medically necessary services on the same day is not something you should be particularly concerned about. If Medicare is reviewing overuse of modifiers in your region, you should simply be extra careful that the modifiers you bill are medically necessary and used correctly. As long as you use the modifier and codes properly, and your documentation proves medical necessity, you shouldn't be worried about whether your claims are being reviewed more carefully by Medicare. 
 
The key is to code and bill for everything you perform, and not to hide or "write off" certain legitimate claims in fear that an auditor might come to your door. Correct coding requires that you code what was performed and documented.
 
You should be able to bill the E/M service in addition to the injection (20550) by using modifier -25. In this case, the diagnosis could be the same, for example, muscle pain (729.1), because CPT dictates that separate ICD-9 codes are not necessary when billing for an E/M and a procedure on the same day. Proving that there is a "significant" difference between the E/M and the injection usually involves showing the carrier a new problem or a major exacerbation of an existing problem.
 
Carrier specificity must be emphasized. For example, in Southern California, Medicare and most local carriers honor modifier -25 and do not require two diagnoses. They reject, however, when the medical documentation indicates that the patient had been previously scheduled to return for an injection, but the doctor instead performed it with the E/M.

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