Primary Care Coding Alert

Question: I heard that if I bill mostly 99213s and keep my E/M billing within the middle-of-the-road range, I-ll avoid the heat for using modifier 25. Is that true?


Arkansas Subscriber


Answer: No, that's not true.

Reality: The HHS Office of Inspector General and other federal watchdogs are sniffing claims with modifier 25, regardless of the coding level. Some providers believe that they can slide under the radar by sticking to mid-level E/M codes most of the time, but this practice won't protect you.

Past problems: The OIG issued a tough report on modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) in 2005, and then CMS followed up last May with Transmittal 954 (CR 5025).

In that transmittal, CMS emphasized that you can use modifier 25 only when the E/M is different from the usual pre- and postoperative work for a procedure. Your doctor must document why the separate E/M was necessary and exactly what he did, CMS said.

Don't use modifier 25 unless the E/M is a separate and distinct service; on these claims, be sure your physician documented a separate exam.