How to Ensure Appropriate Use of Modifier 25

Modifier 25CPT codes are used to report medical procedures and services for processing claims. However, medical coding service providers are well aware that, sometimes, a CPT code may not be sufficient to report a procedure or service. CPT modifiers need to be applied to certain codes to provide additional information about how, where, and why a procedure was performed. Of the many modifiers that can be applied to claims, modifier 25 often causes confusion.

Modifier 25 is defined as a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”

Modifier 25 provides the opportunity to report physician work done when separate E/M services are provided at the time as another E/M visit or procedural service. This permits more efficient use of the physician’s time and could save the patient another visit. However, problems have been reported with the use of modifier 25, and Medicare and other payers scrutinize its use. According to a report published by the American Academy of Orthopedic Surgeons (AAOS), investigations revealed that physicians allegedly misused modifier 25 and received payments. Moreover, improper use of modifier 25 often led physicians to experience systematic claim denials and/or reductions in payments.

Here are the guidelines and best practices for the use of modifier 25.

  • Significant and Separately Identifiable Service
    Modifier 25 indicates that on the day of a procedure, the patient’s condition required a significant and separately identifiable evaluation and management (E/M) service above and beyond the norm. Two significant aspects to note are that the service must be “significant” and “separately identifiable”.

    • Significant: For modifier 25 to order to support an E/M code, the work must be significant. As a recent Medical Economics report clarifies, this means that a problem that requires considerable workup or treatment, or a problem that, if not addressed at the current visit, would need the patient to return for another visit to address it. A minor problem or concern would not support the billing of an E/M service in addition to a procedure.
    • Separately identifiable:¬†To use modifier 25, the documentation should show that the E/M service is above and beyond the usual pre-/post-operative services integral to the procedure. While it is not required to document the E/M visit separately from the pre-/post-op work, the documentation should clearly indicate the work that was performed to support a separate E/M visit.

    In a significant, separately identifiable service, the history, examination and complexity of decision making need to be above and beyond what the provider would normally do. This means:

    • Asking more questions related to the history
    • Examining more organs systems or body areas than what is the norm
    • Complexity is at a certain level like moderate complexity
    • A history, exam and medical decision making were performed
  • Proper Use of Modifier 25

    Moda Health provides the following example of the proper use of Modifier 25:

    The physician sees an established patient for periodic follow-up for hypertension and diabetes. During the visit, the patient asks the physician to address right knee pain which developed after recent yard work. The physician performs a problem-focused history and exam of the patient’s hypertension and diabetes, and adjusted medications. The physician then evaluates the knee and performs an arthrocentesis.

    This visit should be billed using E/M codes 99212-25 and CPT 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance)

    Arthrocentesis reimbursement includes the evaluation of the knee problem. However, the presenting problem for the visit was other than the knee problem. Hypertension and diabetes were separately evaluated (and this evaluation would have been performed if the knee problem did not exist), which makes the use of modifier 25 appropriate.

  • Improper Use of Modifier 25

    Moda Health points out that using modifier 25 would be improper in the following scenario:

    Modifier 25An established patient returns to the orthopedic physician with increasing right knee pain 6 months after a series of Hyaluronan injections. After evaluating the knee and the patient’s medical suitability for the procedure (meds, vitals, etc.), the physician concludes that a second series of hyaluronan injections is required and performs the first of three intraarticular injections.

    The correct CPT code to bill for this E/M visit is 20610. However, it would not be appropriate to append modifier 25 since the focus of the visit is related to the knee pain, which precipitated the injection procedure. The evaluation of the knee problem and the patient’s medical suitability for the procedure is included in the injection procedure reimbursement/RVU, per CMS NCCI Policy Manual.

  • Other Considerations
    In addition to the requirement for the E/M service to be significant and separately identifiable, the following rules apply for the use modifier 25:

    • Modifier¬†25 should always be appended to the E/M CPT code. It should be attached to the established office E/M code¬†(99211‚Äď99215) if provided with a preventive medicine visit.
    • Each¬†CPT service provided should be linked to a distinct¬†ICD-10¬†diagnostic code. This clearly supports the medical necessity of furnishing the E/M-25 service separate from another procedure or E/M service.
    • It is not necessary to have two different diagnosis codes.
    • Documentation should be provided for both the E/M and the procedure
    • The E/M service must be provided on the same day as the other procedure or E/M service. This may be at the same encounter or a separate encounter on the same day.
    • The separately billed E/M service must meet documentation requirements for the code level selected. It will sometimes depend on time spent counseling and coordinating care for chronic problems.

Experienced coders in medical coding companies are well-versed in reporting CPT, ICD-10, and HCPCS codes and appending modifiers to tell the story of what is actually being done at the E/M visit. The support of a reliable service provider can help physicians ensure appropriate reporting of services to prevent denials and maximize reimbursement.