This is part of the Modifier Series, the articles include:
- Modifers 59, 25, and 91
- Modifier 59
Modifiers are valuable coding tools that explain to payers the specific work that was done by a physician during treatment of a patient. They’re important for representing the medical decision-making (MDM) a physician must demonstrate in order to bill, and also be paid for, all the services they render. More specifically, this article is going to explore modifier 25, which is a modifier you will see frequently if your provider bills E/M services. In order to better understand modifier 25, we will start by explaining what exactly it is, then discuss how and when to use modifier 25.
DEFINING MODIFIER 25
As mentioned earlier, modifier 25 is a particularly meaningful coding tool for physicians who bill for evaluation and management (E/M) services. CPT guidelines define the 25 modifier as “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”
In other words, modifier 25 reports that the physician performed an exam that qualified as significantly separate from any other services rendered that day. But what actually qualifies that exam as ‘significantly separate’ from the rest? Let’s get some clarification by reviewing examples of modifier 25 in use.
CLINICAL SCENARIOS
The following are three examples of when to use modifier 25 to appropriately code for a provider’s services:
Example One:
A dermatologist examines an established patient during a regularly scheduled skin check and performs a head-to-toe skin exam. During the patient’s exam, a new suspicious skin lesion is discovered. The physician determines this should be biopsied and performs a punch biopsy.
In this scenario, the E/M would qualify as a separately identifiable service (updating patient history from the past year, skin exam of moderate-high complexity, and MDM) from the procedure of the biopsy. The correct and appropriate reporting for this visit would be to add modifier 25 to the E/M and code the completed services as follows: 99213-25, 11100.
Example Two:
A woman comes into her OBGYN office for an appointment and reports to her physician that she has recently experienced abnormal bleeding and pain. However, after a pelvic exam and regular PAP smear are conducted, these reported symptoms do not appear to have an obvious cause. The OBGYN deems a pelvic ultrasound to be necessary to investigate this patient’s problem further.
Modifier 25 would be applicable to the E/M in this scenario, as the ultrasound procedure was used in an attempt to diagnose an abnormality and is not a procedure that should be considered included a routine OBGYN office visit; 99213-25; 76830.
Example Three:
A patient visits his cardiologist and presents with a complaint of chest pain during physical exertion. This patient has a personal history of high blood pressure controlled with medication. After the physician has completed the E/M, he determines the patient requires a cardiovascular stress test, which is conducted later the same day by the same physician.
To prevent the E/M from being bundled into the stress test, the cardiologist’s coder would use modifier 25 to show that the two services were separate and significant; 99213-25, 93015.
JUSTIFYING USE OF MODIFIER 25
As with all matters of provider service billing, understanding the necessity of justification of services performed is mandatory. In a word (or maybe three): document, document, document. Especially with modifier 25, clear, detailed physician documentation is key to supporting the MDM involved during the course of the treatment rendered.
The provider must demonstrate their thought process in the required documentation, as it will serve a critical role; without a proper medical record, payers may continue to render determinations of incorrect claim denials or underpayments. With proper supporting documentation, even if a payer is incorrectly denying services, the physician’s billing staff will have a leg to stand on when filing claims reconsiderations.
SUMMARY
Understanding the correct and appropriate use of modifier 25 will be key to filing correct claims, which will then result in correct payment. Not only does the 25 modifier allow us to code physician services to the highest level of specificity possible, but it ensures the physician is paid accordingly for those services. However, this doesn’t mean coding and reimbursement is all dependent upon modifier 25 alone; physicians are responsible for sufficiently documenting the need for E/M services separate from the procedure/s subsequently performed. Physicians and their coding and billing staff will need to work as a team in order to create the clearest and accurate E/M claims, fully supported with proper medical documentation.
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