I work for a critical access hospital in the billing department and we have been instructed by Aetna and our upper administration to add a 25 modifier to every E&M that includes billing for images. I have requested this to be sent to me in writing. I think it is over use of a 25 modifier. I have always worked in a private practice so hospital billing is new to me and I was told that critical access is different. Any help would be greatly appreciated. Thanks!
Hello,
Curious to know what the outcome was. I researched this myself and found the following:
You didn't mention if this was Aetna Medicare Advantage or Aetna Medicaid or the state.
I did find on Aetna Medicaid for Florida examples of how Modifier 25 can be used.
Page 18 of the link:
https://www.aetnabetterhealth.com/c...ovider Billing and Claims Training 07.20.pdf
Novitas Solutions has a great Modifier 25 Fact Sheet that also mentions when not to use mod -25.
www.novitas-solutions.com
From the AMA website regarding proper use of modifier 25 and questions to ask yourself regarding the appropriateness of mod 25 in those circumstances.
I will put two excerpts from the AMA article which may help to answer your question.
Modifier 25 is used to signify that when a separate identifiable evaluation-and-management (E/M) service was performed, which can refer to two evaluation-and-management (E/M) services, or a procedure plus an E/M service.
Appending the CPT modifier 25 to an E/M service code on a claim indicates the code is a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service, the
AMA issue brief (PDF) explains.
“Its use allows two E/M services or a procedure plus an E/M service that are distinctly different but required for the patient’s condition to be appropriately reported and, therefore, appropriately paid,” the issue brief says.
The use of modifiers provides supplementary information for payer policy requirements. Payers, however, may not be aware that this is what the modifier is telling them.
“Unfortunately, there is a disconnect between physicians and payers regarding the feasibility of providing, documenting, reporting, and paying for multiple services,” according to an AMA Council on Medical Service report presented at the 2023 AMA Annual Meeting.
The use of modifier 25 “indicates that documentation is available in the patient’s record to support the reported E/M service as significant and separately identifiable,”
the council report (PDF) adds.
Policies support use of modifier 25
According to the issue brief, answering “yes” to the following questions shows whether an E/M service justifies use of modifier 25 according to CPT guidelines:
- Did the physician perform and document the level of medical decision making or total time necessary to report a problem-oriented office or other outpatient E/M service for the complaint or problem?
- Could the work to address the complaint or problem stand alone as a reportable service?
- Did the physician perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code?