Primary Care Coding Alert

Question: I don't think our office is using modifier 25 correctly. Does this get used even when we complete a simple office lab, such as a throat culture or urine dip? I'm asking because one of our coders uses modifier 25 when we give a flu shot. Should we use it with every additional thing we do during a visit?

Connecticut Subscriber

Answer: The first rule to remember for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is that you can only append it to E/M codes. Modifier 25 applies when the physician conducts another service during the encounter in addition to the E/M service.

Verify that you have adequate documentation explaining both services, however, before reporting modifier 25. Typically, you only need to append modifier 25 to an E/M code when reporting other codes on the same date of service that may also be perceived to have a certain evaluation and management component to them. This includes, for example, minor procedures and other E/M services (e.g., a preventive medicine E/M service done at the same encounter as a problem-oriented E/M service). Provision of simple office labs done with an E/M service do not typically necessitate appending modifier 25 to the E/M code.

If in doubt about whether to append modifier 25 to the E/M code, consider the following. First, check the National Correct Coding Initiative edits to see if the E/M code and other code(s) you will be reporting are bundled in the absence of a modifier. If so, append modifier 25, when appropriate.

Second, look at the CPT® guidelines for the non-E/M codes in question. For instance, in the guidelines preceding the vaccine administration codes, CPT® states, "If a significantly separately identifiable Evaluation and Management (E/M) service (e.g., office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes." Although CPT® doesn't specifically say you need to use modifier 25 in this instance, the phrase "significantly separately identifiable" E/M service certainly suggests use of modifier 25 may be in order.

Example 1: Mr. Barker comes to the office for a follow-up regarding his hypertension (401.x, Essential hypertension, or 405.xx, Secondary hypertension). While he's in the office, the staff administers a flu vaccine. Report the appropriate E/M code for the office visit/follow-up care and append modifier 25. Then also report the flu vaccine and administration.

Example 2: When your receptionist calls to confirm Mr. Barker's appointment, Mrs. Barker asks if she can come with him and get a flu shot. Because that's the only procedure or service performed, you'll code for the flu vaccine and its administration but will not report an E/M code or modifier 25 in conjunction with Mrs. Barker.