Modifier 25 – Understand the Facts to Avoid Misuse

by | Jul 6, 2017 | Medical Coding News, Resources | 0 comments

CPT modifiers provide additional information for claims processing. However, the proper use of modifiers is a major concern for hospitals and physician practices, which is why medical coding companies pay special attention to this while reporting claims. CPT code modifier 25 is one of the 83 target codes that the Centers for Medicare and Medicaid (CMS) targets for review in the 2017 Medicare Physician Fee Schedule Proposed Rule.

Modifier 25 can be appended to claims where the provider “renders a significant, separately identifiable evaluation and management (E/M) service to the same patient on the same day as another procedure or service”. It should be only be used when services are provided beyond those considered to be part of the procedure performed.

In 2005, the Office of the Inspector General (OIG) had identified the overuse of modifier 25 and reported that 35% of the claims using Modifier 25 did not meet the billing guidelines, resulting in improper payment of millions of dollars. In 2016, the CMS again identified the possible overuse and misuse of modifier 25. Medicare’s CY 2015 claims review showed that 19% of the codes that describe 0-day global services were billed more than half the time with an evaluation and management (E/M) service with modifier 25 appended.

Improper use of Modifier 25 continues to be a problem. Last month, the University of Rochester Medical Center (URMC) was pulled up last month for misusing it. Democrat & Chronicle reports that URMC will pay $113,722.10 after a lawsuit alleged it violated the federal and New York False Claims Act by using a billing modifier in an improper manner on certain health care claims at UR’s Flaum Eye Institute. According to the report, modifier 25 was incorrectly used for intravitreal injections (injections into the eye). Authorities said URMC performed and billed for this ophthalmology procedure, but that “the medical records lacked sufficient documentation to support billing for care beyond the injection procedure itself”.

Criteria for the Use of Modifier 25

A report in the Bulletin of the American College of Surgeons (ACS) distinguishes between Medicare’s criteria for the use of modifier 25 and CPT’s requirements.
As per CMS, modifier 25 should be used only on claims for E/M services and only when the E/M service is provided by the same physician on the same day as a global procedure or service. To be eligible for payment, the physician should indicate that the service is for a significant and separately identifiable E/M service that is above and beyond the usual preoperative and postoperative work required on the day of the procedure. Both the medically necessary E/M service and the procedure in the patient’s medical record must be appropriately and sufficiently documented to support the claim for these services, even though it is not required to submit documentation with the claim.

The CPT codebook defines modifier 25 as a significant, separately identifiable E/M service that the same physician or other qualified health care professional provides on the same day as the procedure or other service. Also, according to CPT guidelines, a significant, separately identifiable E/M service is substantiated by documentation that meets the relevant criteria for the respective E/M service to be reported.

The catch is: what does “significant and separately identifiable” mean?

Meaning of “Significant and Separately Identifiable”

To append modifier 25, physicians should be aware of whether a service performed is “significant and separately identifiable”, and can be therefore documented as a significant and separately identifiable E/M service. Many providers wrongly believe that evaluating the condition and deciding to perform a minor procedure makes them eligible to report an E&M service on the same day as the procedure. This is incorrect.

According to the National Correct Coding Initiative (NCCI) manual, “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. …If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”

Modifier 25 can be appended to an Evaluation and Management (E&M) service to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. In other words, when a significant and separately identifiable E&M service is provided unrelated to the decision to perform the minor surgical procedure, this service is separately reportable with modifier 25.

Appropriate Use of Modifier 25

  • Modifier 25 is used only with evaluation and management (E&M) codes. Do not append modifier 25 to the procedure code.
  • Do not report an E/M code each time a minor procedure is performed in an office or facility as minor procedures already include E&M elements; modifier 25 should be used only when services are performed over and above what is typical for the procedure.
  • The same provider must provide an E/M service and another/separate procedure for the same patient on the same day. All physicians who share an NPI in group practice are considered as the same provider from a coding perspective.
  • The E/M service must be significant and above and beyond the pre-service time associated with the procedure. The extended E/M work should be medically necessary.
  • To support the use of modifier 25, both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented in the patient’s medical record.
  • Rare circumstances can warrant the use of modifier 25. For instance, ACS says that E/M service the day before a major operation represents a significant, separately identifiable service and likely to be associated with a different diagnosis (for e.g., evaluation of a cough that might affect the operation).
  • Different diagnoses are not required to report the E/M service on the same date as the procedure or other service.

According to the American College of Cardiology (ACC), Modifier 25 should not be used in the following situations:

  • When billing for services performed during a postoperative period if related to the previous surgery
  • If only an E/M service was performed during the office visit and no procedure was done
  • On any E/M on the day a “Major” (90 day global) procedure is being performed
  • For an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable
  • The patient came in for a scheduled procedure only

The use of modifiers is a critical element in medical billing for health care services. With CMS notifying increased focus on modifier 25 in the 2017 Physician Fee Schedule Proposed Rule, providers need to scrutinize their claims and documentation to ensure that this modifier has not been misused.