Primary Care Coding Alert

Hint: understand “above and beyond” to justify E/M-25.

“If we’re going to talk about procedures in the office, then we have to talk about 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],” said Jaci J. Kipreos, CPC, CDEO, CPMA, CEMC, COC, CPC-I, president at Practice Integrity LLC, San Diego, at the beginning of her HealthCon 2021 presentation “Coding for Common Procedures in a Primary Care Setting.”

But using the modifier isn’t easy. “It’s always under scrutiny … it’s unique. And different payers have different rules. So, we have to decide ‘what is the documentation telling me? What’s the purpose of the encounter?’” Kipreos continued.

Here, then, are five things you should know to help you determine if you have used modifier 25 correctly on a claim.

1) Know the Purpose of the Encounter

“What does that first line of the documentation say? If it stated that the patient presented for a procedure, then that is what your provider will be doing. So, using modifier 25 means that something else is going on,” said Kipreos.

In other words, if all a patient is doing is presenting for a vaccination, and that is the only thing that occurred during the encounter, then you cannot bill for an evaluation and management (E/M) service. That also means you cannot use modifier 25 on the E/M to show that it is significant and separate from the procedure.

2) Know Additional Workups Unrelated to the Procedure

Once your provider’s documentation goes beyond describing the initial procedure, there is the potential for documenting a significant and separate E/M.

One such thing to look for in the record to determine this would be orders for additional labs or diagnostic tests, X-rays, studies, or even referrals to a specialist. Such additional workup, providing that it is unrelated to the procedure, will build a strong case for E/M-25.

3) Know if the Provider Began a New Treatment Plan

Similarly, if the provider indicates the encounter involved discussing a condition or existing problem that is completely unrelated to the condition the current procedure is treating will also build a strong case for E/M-25.

4) Know if the Provider Did Additional Work Above and Beyond the Procedure

Perhaps the most important determination you will need to make before billing for a separate E/M with modifier 25 is deciding whether your provider performed any additional work above and beyond the work involved in the procedure. This means knowing what typical pre- and post-work is included in the procedure code.

In our vaccination scenario, pre-work for 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) would include such things as “site assessment, the decision to perform the procedure, obtaining the patient’s informed consent, obtaining information about allergies, and obtaining information about immunization,” while the post-work would “include post-procedural instructions,” Kipreos noted. None of this work can be used to justify a separate, significant E/M.

Conversely, you should also ask whether your provider “spent additional time on the procedure, or if there was something unique or unusual about it,” Kipreos noted. If either is true, that does not automatically mean you should be dusting off modifier 25. But it does mean you should scrutinize your provider’s documentation, or query your provider, to see if you can make the case for a significant and separate E/M.

Expert Coding Tip: In general, modifier 25 should 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 involve appending modifier 57 (Decision for surgery) to an E/M service provided on the same date, assuming the E/M service resulted in the initial decision to perform the surgery.