Primary Care Coding Alert

Clear up coding confusion with the answers to these four simple questions.

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is probably one of the most used, and one of the most misused, modifiers that you can employ in your coding.

Small wonder, then, that “appropriate use of modifier 25 has often been on the Office of the Inspector General’s [OIG’s] Annual Work Plan,” according to Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC,  revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

“The OIG reviews use of modifier 25 and may audit organizations that overuse the modifier. This is also true of Medicare Administrative Contractor [MAC] and Recovery Audit Contractor [RAC] audits,” Bucknam cautions. So, we’ve prepared this timely reminder of the correct way to use modifier 25 and added to it some examples of how the modifier should, and should not, not be used.

What, Exactly, Does a Modifier Do?

Before looking at modifier 25’s role in depth, a reminder of the two functions any modifier performs is in order. CPT® defines those functions as:

• Providing “the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code,” and
• Enabling “health care professionals to effectively respond to payment policy requirements established by other entities.”

In other words, modifiers allow you to indicate when circumstances require a provider to change a service or procedure described by a specific CPT®  code without changing the underlying code itself. This, in turn, enables payers to determine what the provider did and how, or even if, they should pay for that particular service.

How Is Modifier 25 Misused?

If you read the modifier’s descriptor closely, you can begin to see some of the problems you can encounter when using it. Simply put, if the procedure or other service is not on the same day, if the E/M service is not significant or separate from the procedure, and if the same physician or qualified healthcare professional (QHP) did not perform both the E/M service and the procedure (or if either service was performed by someone other than a physician or QHP), then you have incorrectly applied the modifier.

Example: Your office schedules a patient for a leg lesion removal, and your provider performs 11401 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm). “Billing a separate E/M service with modifier 25 in this scenario would not be appropriate,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “This is because the lesion removal was the sole reason the patient came to the office. The provider did not perform a significant or separately identifiable E/M service, so you cannot charge for it.”

Coding caution: In general, modifier 25 should also only be used on E/M services performed in conjunction with minor procedures that have a 0- or 10-day global period. Procedures with a 90-day global period will typically take modifier 57 (Decision for surgery).

How Should I Use Modifier 25?

If, on close examination of a provider’s notes, you can separate out a history, exam, and/or medical decision making (MDM) that add up to a specific E/M level, then you likely have a case for appending the modifier to the E/M service in question. You should note, too, that you don’t necessarily have to have a separate diagnosis to justify the E/M.

Example: An established patient presents with a 2 cm laceration to the forehead after she fell from her bike just before arriving at your office. Your provider reviews her vaccination record to make sure her tetanus shot is up to date, checks the patient for headaches and nausea, palpitates and inspects the area around the laceration for any other deformity and, in the absence of any other problems, performs 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less), giving the patient instructions to keep the bandage clean and dry and return in 10 days.

“The clear extra and separate work the provider performs to identify the patient’s immunization status, possibility of a fracture, and concerns for a possible concussion, even though the other conditions are ruled out, documents that your physician provided separate work in addition to the laceration repair,” says Bucknam. “This means you can bill an E/M service separately using modifier 25.”

Coding alert: “Contrast this with a note that says, ‘the patient presents with a laceration on the forehead, the wound is cleaned and examined, and five stiches are applied to close the wound.’ You would not be able bill for the E/M service in this case, not just because the length of the note but because no work is documented above and beyond the work involved in the procedure itself,” Bucknam reasons.

The Bottom Line

Before you submit any more claims featuring modifier 25, “you should ask yourself the four following questions,” says Falbo.

• Was the procedure or service unscheduled?
• Did the E/M service uncover signs and symptoms in the patient that the provider must address with a procedure or service?
• Did the provider address more than one diagnosis?
• Did the provider perform work that went above and beyond normal preoperative and postoperative work?

“Answer ‘yes’ to any of them, and an there’s a good chance that an E/M service with modifier 25 appended will be seen as medically necessary providing you have the documentation to support it,” Falbo concludes.