Podiatry Coding & Billing Alert

Question: Typically, my claims that include modifier 25 are denied. How do I use this modifier correctly?

Texas Subscriber

Answer: Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is one of the most misunderstood modifiers. E/M service codes, ranging from 99201-99499, are the only codes to which you may append modifier 25. Modifier 25 cannot be looked at in a vacuum; you must understand how it relates to having supporting chart notes, and correct usage with E/M codes. Many doctors unknowingly misuse modifier 25. You must pay attention to the words 'significant' and 'separately identifiable.'

For example, if you report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components...) and 11040 (Debridement; skin, partial thickness) and add modifier 25 to 99213, you are telling Medicare that the services were unrelated and you are justified in getting paid for both 99213 and 11040.

Many commercial carriers will not pay for each procedure, even with modifier 25 added appropriately. Instead, they will bundle the codes together and pay only one code, regardless of whether you have a modifier 25 present or not. Adding modifier 25, however, to your E/M code at least gives you grounds to appeal.

Remember: In order to appeal, you need good, detailed notes. They should clearly indicate that your modifier 25 use was justified and was, in fact, for a significant and separate service.