Urology Coding Alert

CPT Codes says modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) can be used to obtain payment for a separately identifiable E/M service provided at the same encounter as a minor procedure. Although many private payers require two diagnoses with modifier -25, Medicare allows the same diagnosis code to be used.
 
But Medicare is trying to control the use of modifier -25: Recall the massive edits of October 2000, rescinded in the next version of Correct Coding Initiative (CCI), which bundled numerous procedures with E/M services. After that, CMS announced that it would educate providers about the correct use of modifier -25. Since then, however, the CCI Edits contractor has changed and the nationwide education on modifier -25 has not occurred.
 
Some carriers are clarifying what they mean by "separately identifiable," which requires great care when you decide whether to bill an E/M visit with a minor procedure. Watch for signs that your carrier is scrutinizing modifier -25, perhaps with the aim of conducting its own provider education. 
 
For example, Administar Federal, which covers Indiana and Kentucky, posted a notice on its Web site Jan. 29, 2002:
 
The Carrier has learned that modifier -25 is being inappropriately appended to E/M codes that are not "separately identifiable" from the minor surgical procedure performed on the same day. The narrative definition for modifier -25 is as follows: "Significant, separately identifiable evaluation and management service by the same physician on the same day as a minor procedure." In order to be separately payable, any E/M service performed above and beyond the minor procedure must meet medical necessity requirements, e.g., must not represent a screening examination. Once medical necessity is established, the service must also represent a separate issue or condition from the minor procedure in order for modifier -25 to be used appropriately. The fee for surgical procedure codes includes payment for preoperative and postoperative services. Therefore, a duplicate payment would result if an E/M service is routinely billed during the same encounter as a minor procedure, by attaching modifier -25 to an E/M code when that service is not separately identifiable from the minor procedure done the same day.
The announcement does not include the part of the CPT modifier -25 definition that specifically allows there to be only one problem: "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date."
 
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