Billing Code Confusion: How to Use Modifier -25
Modifier -25 is a useful and frequently used CPT modifier, but confusion over when and how to use it may lead to audits. The code is meant to capture significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service. This is important because it allows physicians to properly code separate E/M services provided at the time of another E/M visit or procedural service. For example, a surgery that can be done on the same day as the initial diagnostic office visit. In that case the physician may want to bill an office visit with an appended modifier -25 versus simply billing for the procedure. Is one way more correct than the other? A recent article published in Cutis seeks to clarify the question.
Modifier -25 use has come under increased scrutiny by insurers and regulators as 35% of claims using modifier -25 that Medicare allowed did not meet the appropriate requirements. Some private insurers have started to discount reimbursement for office visits billed with modifier -25 due to this perceived overuse. The CPT guidelines make it clear that to appropriately bill both the E/M service and the procedure, the physician must indicate that the patient’s condition required an E/M service “above and beyond the usual pre- and post-operative work of a procedure.” But, as the article notes, it is up to the physician to decide what qualifies as a significant, separately identifiable E/M service. Modifier-25 can streamline care and save the patient multiple visits, but in order to avoid billing mistakes, it is critical that practices understand what should be offered in the global surgical package.
The global package, which is the typical group of services with a procedure, includes: local or topical anesthesia, the surgical service/procedure itself, immediate post-op care including dictating the operative note, meeting/discussing the patient’s procedure with family and other physicians, evaluating the patient in postanesthesia/recovery area, and writing orders for the patient. If the procedure is minor, the package also covers same-day E/M associated with the decision to per¬form surgery. However, it should be noted that if an E/M service is performed on the same day as a minor procedure to decide whether to proceed with the minor surgical procedure, this E/M service cannot be separately reported. So, in the example given above, the Modifier-25 should not be used.
The article goes on to describe scenarios that better illustrate when to use Modifer-25. The author concludes that in order to avoid abuse of the modifier and subsequent risk of audit, providers should provide complete documentation of the additional E/M service provided and note any treatment considerations above and beyond those typically required by the minor procedure.
Byline: Martha L. Sikes, MS, RPh, PA-C
Posted: April 3, 2017
Adapted from the original article.