Modifier 25 indicates that on the day of a procedure, the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
A significant separately identifiable Evaluation and Management service is defined or substantiated by documentation that satisfies the relevant criteria for the respective Evaluation and Management service to be reported. Also, everytime while coding different diagnoses are not required for reporting of the E/M services on the same date, as the Evaluation and Management service may be prompted by the synonym or the condition for which the procedure or service was provided. What needs to be noted is this modifier is not to be reported with an Evaluation and Management service that resulted in a decision to perform surgery.
The use of modifier 25 has specific requirements as per the CPT Manual:
- The Evaluation and Management service must be significant. The problem must warrant physician work that is medically necessary.
- The Evaluation and Management service must be separate. Only in case of preventive medicine, the problem must be distinct from the other Evaluation and Management service provided. Otherwise, it is not necessary to have two different diagnosis codes. Separate documentation of E/M -25 helps in supporting the use of modifier 25 and any denial appeal.
- The Evaluation and Management service must be provided on the same day as the other E/M service.
- Modifier 25 should be attached to the Evaluation and Management code. If provided with a preventive medicine visit, it should be attached to the established office E/M code (99211?99215).
The services where Evaluation and Management with modifier 25 can be reported are as follows:
- Anticoagulant Management
- Preventive Medicine Services
- Newborn care services.
- Inpatient Neonatal and Pediatric Critical Care
- Transcatheter Thrombolytic Infusion.
- Transplantation and Post-Transplantation Cellular Infusions.
- Hemodialysis
- Miscellaneous dialysis procedure
- Allergy and clinical immunology
- High Complex Drug or Highly Complex Biologic Agent Administration.
- Acupuncture
- Osteopathic Manipulative Treatment
- Chiropractic Manipulative Treatment
- Home Health Procedures
Modifier 25 can be used for outpatient, inpatient, and ambulatory surgery centers hospital outpatient use and emergency department visits.
Other issues include that when both an Evaluation and Management service and procedure are billed on the same day, the documentation needs to support both codes. A history, exam and medical decision making (or two of three key elements, depending on your E/M code) separate from the procedure should be documented. Another concern is the medical necessity for the E/M service, although under the CPT guidelines for certain services different diagnosis is not required.
Example 1
A 7-year old established patient visits his family physician for preventive medicine examination. All necessary components of a preventive medicine Evaluation and Management visit are provided including hearing and vision screening, appropriate laboratory tests, and immunizations. He has been diagnosed Hyperkinesis with developmental delay . The patient is evaluated for his Hyperkinesis and multiple parent concerns are discussed. Fifteen minutes of face-to-face physician time is spent in counseling for this problem, addressing parent concerns and behavior management.
Complete documentation of the preventive medicine visit is made . The Hyperkinesis is separately documentated with 15 minutes devoted to counseling for this diagnosis.The coding will be as follows:
CPT | ICD – 9 – CM | ICD – 10 – CM |
99393(Preventive medicine (5-11 yrs) | V20.2 | Z00.129 |
99213-25(Established patient,15 minutes) | 314.1 | F90.8 |
Example 2
A 15-month-old girl presents with a fever (102?F) and mom states the girl has been tugging at her right ear for 2 days. A detailed history is obtained and a problem-focused examination is completed. When the doctor examines the ears he notices that the middle ear is very inflamed (pus is present) . The doctor decides to administer Ceftriaxone sodium to the child. The final diagnosis is acute suppurative otitis media without rupture of eardrum.
Coding
CPT | ICD – 9- CM | ICD – 10 – CM |
99213-25 | 382.00 | H66.001 |
J0696 | 382.00 | H66.001 |
However, payers like Medicaid do not accept this modifier and hence results in a denial. The Centers of Medicare and Medicaid Services (CMS) requires that modifier 25 should only be used on claims for Evaluation and Management (E/M) services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service. Unfortunately, not all insurers will pay for the separate E/M service even if you code in compliance with the CPT rules. A review of the documentation by the insurer or having the staff appeal any denied or bundled claims may actually result in the payment of the work.
One last note
The carrier in most cases would pay for both the services, when a claim is submitted to the insurance that is coded with modifier 25. Some insurance companies may require separate co-payments on both the services. An appeal may help in dropping one of the co-payment, but sometimes there would be a need to comply with the plan’s requirements. However, it is important to know the payer’s policy to avoid such situations.
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