Ending Confusion Over Modifier 25

March 11, 2024

It’s a big week here in Boston (my hometown). Sunday, of course, is St. Patrick’s Day. Here in Boston, we also remember March 17 as Evacuation Day—marking the anniversary of the British army leaving the city in 1776. Either way, it’s a day to celebrate. Here are a few codes you may need to apply.

R44.1	Visual hallucinations. Too much of that green beer sometimes makes people see strange things
B27	Infectious Mononucleosis. “Kiss me, I’m Irish,” may be the sentiment on St. Patrick’s Day, but it can also expose your patients to the “kissing disease” (as infectious mononucleosis is sometimes called).
T65.6X1A	Toxic effects of paints and dyes. Another risk from drinking too much green beer.
F10.1296	Alcohol abuse with intoxication, unspecified. This code is a no-brainer on St. Patrick’s Day and may be accompanied by a diagnosis of dizziness and giddiness (R42) and slurred speech (R47.81).
W22.02XA	Walked into a lamppost. Intoxication may be the underlying cause, but this particular result gets its own code

Now let’s get to a topic that continues to create confusion for providers and coders alike: the correct way to apply Modifier 25 in E/M coding.
Here’s a brief overview:

Modifier 25 is applicable when a patient requires “significant, separately identifiable” Evaluation and Management (E/M) by the same physician or other qualified healthcare professional above and beyond a procedure or other service (beyond usual pre-operative and post-operative care associated with a procedure) they received on that same date. A “significant, separately identifiable E/M service” is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

Coding at a level below what is appropriate creates two problems for provider groups. First, they needlessly leave billable revenues that they have legitimately earned on the table. Not many groups can afford to do that in an environment where costs are rising and reimbursements are shrinking. Second, though it may seem counterintuitive, providers who bill at a level below what the evidence supports risk being audited, too; it happens to those being underpaid by insurers as well as those who are found to “over-code.”

Here are some guidelines for using Modifier 25 correctly: 

• Use Modifier 25 when a surgeon performs an E/M service or eye exam on the same day as a minor surgery (with 000 or 010 global days). This indicates that the E/M service is distinct and separately identifiable from the typical work associated with the surgery. 
• New patient CPT codes are required when a separately identifiable E/M service is performed on the same day as chemotherapy or non-chemotherapy infusion or injections (not considered surgery). 
• A different ICD-10 code from the one submitted with minor surgery is not necessary for an E/M code. The diagnosis for the E/M service and other procedures may be the same or different. 
• Use Modifier 25 when an E/M service is provided on the same day as another procedure typically bundled under the National Correct Coding Initiative (NCCI). This modifier indicates that the E/M service was performed for a reason unrelated to other procedures. 
• To bill for an E/M service, ensure a history, exam, and medical decision-making (HEM) are included. All procedures inherently involve some service related to patient evaluation and management. A separate E/M service should have its own HEM, and physicians must assess whether the problem necessitates additional work for performing critical components of a problem-oriented E/M service. 

Do NOT use Modifier 25: 

• With E/M codes explicitly designed for new patients; 
• When another physician, not performing the procedure, is involved; 
• If the documentation indicates that the amount of work performed is consistent with what is normally undertaken with the procedure; or 
• If billed with a procedure or service that falls under a no-global-fee period. 

¹https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Don’t miss our “Ask the Experts” Q&A webinar on March 27! Click here to register: https://zoom.us/webinar/register/WN_DR96lTB4QVWgI5b2wxmKuw If you have an E/M coding question you’d like our experts to address during the webinar, please submit it here: https://survey.hsforms.com/1AI9VoMe-SK6MSUuAypFnmgnig0s

 

Got a question about E/M coding? We’d love to hear from you. Submit your questions by emailing us at coders@calmwatersai.com

 

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