Modifier 25 Examples
Modifier 25 Definition
The Current Procedural Terminology (CPT) book defines Modifier 25 as a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. It may be necessary 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 this article, we shared modifier 25 examples along with the basics of modifier 25. This will give you guidelines on how to use modifier 25 appropriately.
When to use Modifier 25
The key is recognizing when your extra work is “significant” and, therefore, additionally billable. CPT does not define “significant,” but asking yourself the following questions should lead you to the answer:
- Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?
- Could the complaint or problem stand alone as a billable service?
- Is there a different diagnosis for this portion of the visit?
- If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?
If your answers to these questions are yes, then you should report the appropriate E/M code with modifier -25 attached as well as the preventive medicine service code or minor surgical procedure code. You can increase the likelihood that the insurer will pay for both services by organizing your note so that documentation for the problem-oriented E/M service is separate from documentation for the preventive service or procedure.
Modifier 25 Examples
A new patient presents with head trauma, loss of consciousness at the scene, and a 4.2 cm scalp laceration. The physician determines that the laceration requires sutures, so he performs a simple repair. Due to the loss of consciousness, the physician also performs a full neurological examination with an expanded problem-focused history, expanded problem-focused examination, and medical decision making of low complexity.
In this example, the problem/abnormality is significant enough to require the additional work of the key components of a problem-oriented E/M service separate from what was needed for the laceration repair. So, this visit would be coded as 12002 and 99202 -25.
The possible neurological damage from the head trauma extended beyond the laceration, which was repaired. The full neuro exam, history, and medical decision making outside of the laceration issues are separate and distinct, significantly separate and well documented to support the use of modifier 25.
A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed that day by the same physician.
The physician codes an E/M visit (99201 – 99215) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure. So, this visit would be coded as 99214 – 25 and 93015.
The modifier stops the bundling of the E/M visit into the procedure. When reviewing the physician’s documentation the carrier should be able to determine that both the E/M and the procedure were medically necessary. As always, the documentation has to support the claim that your office sends to the carrier.
An established patient is seen for periodic follow-up for hypertension and diabetes. During the visit, the patient asked the physician to address right knee pain which developed after recent yard work. The physician performed a problem-focused history and exam of the patient’s hypertension and diabetes, and adjusted medications. Then the physician evaluated the knee and performs an arthrocentesis.
The evaluation of the knee problem is included in the arthrocentesis reimbursement. The presenting problem for the visit was other than the knee problem. A separate evaluation of hypertension and diabetes was performed (and would have been performed if the knee problem did not exist), making the use of modifier 25 appropriate. So, this visit would be coded as 99212-25 and 20610.
When you submit a claim to the insurance carrier that is coded with a 25 modifier, you are telling the carrier to pay you for both the E/M visit and the minor procedure. Often in the past claims with both an E/M and procedure have been reviewed for accuracy. When you bill both codes on the same day will your documentation support both codes? Will you have documented history, exam, and medical decision making (or two of three key elements, depending on your E/M code) separate from the procedure? Typically, when these services have been audited payment was rescinded due to incorrect coding, incomplete documentation, and/or lack of medical necessity to support both codes billed on the same day by the same physician. Modifier 25 can be used for outpatient, inpatient, and ambulatory surgery centers hospital outpatient use. Modifier 25 can be used in other situations such as with critical care codes and emergency department visits.
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Unfortunately, not all insurers will pay you for the separate E/M service even if you code in compliance with CPT rules. Be sure to have your staff appeal any denied or bundled claims. A review of your documentation by the insurer may actually result in payment for your work. Still confused after reading examples for modifer 25? Don’t worry E2E Medical Billing Services has an experienced coding team that uses exact modifiers to avoid denials. To know more about our medical billing services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com