PROCEDURE CODING: WHEN TO USE THE MODIFIER 25
Modifiers provide payers detailed information about what a doctor did while working with their patient. Modifiers play a crucial role in demonstrating the required medical decision-making (MDM) that a physician must show to bill and get paid for all services provided. This article is about modifier 25 and its application in different circumstances.
DEFINING MODIFIER 25
Modifier 25 indicates that a patient’s condition requires a distinct and substantial evaluation and management (E/M) service, separate from any other procedures or services performed on the same day by the same physician or healthcare provider. It helps to distinguish an E/M service that is significant enough to be billed separately from other procedures that may have been conducted during the same visit.
CLINICAL SCENARIOS
Here are three instances where it is suitable to use modifier 25 for coding the services of a provider:
EXAMPLE ONE:
During an examination, a clinician stumbles on a suspicious skin lesion. After due deliberation, he concluded it needed a punch biopsy. The E/M would be a separately identifiable service (updating patient history from the past year, skin exam of moderate-high complexity, and MDM) from the biopsy procedure.
EXAMPLE TWO:
A patient enters her OBGYN’s office and complains of unusual recent bleeding and pain. However, no clear cause is identified even after a pelvic exam and routine PAP smear. The OBGYN finds it necessary to carry out a pelvic ultrasound to investigate the issue precisely. Modifier 25 applies here as the ultrasound procedure was used to diagnose an abnormality.
EXAMPLE THREE:
A man goes to see a cardiologist and reports chest pain while doing physical activity. The patient had experienced hypertension in the past, though it was under control with medication. Post E/M from a physician: The patient needs a Cardiovascular stress test. The same day, this test was done by the same doctor who had done the E/M earlier.
If the E/M is not bundled into the stress test, then the Cardiologist’s coder can use modifier 25 to indicate that these two services were separate and significant: 99213-25, 93015.
USE OF MODIFIER 25
Like any other provider of service billing, the point about needing to justify services performed is significant here, too. When using modifier 25, physicians must provide clear and detailed documentation to back up the MDM involved in the treatment given.
The provider’s thought process needs to be seen in the required documentation, as it will play an essential part; without a complete medical record, payers could keep making decisions like wrong claim denials or paying too little. If there is proper support paperwork, the doctor’s billing staff can fight back by submitting claims reconsiderations even though the payer wrongly denies services.
CONCLUSION
Understanding modifier 25 and using it appropriately is significant to file accurate claims, leading to proper payment. Applying modifier 25 allows us to code physician services correctly and guarantees that they are paid for as such. However, it is not entirely true that coding and reimbursement rely solely on modifier 25; physicians must sufficiently document why E/M services were needed apart from the procedure/s done later. Doctors and their coding and billing teams must collaborate effectively to generate the most transparent and precise E/M claims backed by correct medical records.
