Health Information Management

Q/A: Use of modifier -25

APCs Insider, July 17, 2009

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Q: We know we should append CPT modifier –25 to the visit level when one of our EDs or clinics codes a separately identifiable procedure with an S or T status indicator in addition to a visit level. The OPPS rules changed in 2009, and now modifier –25 is necessary in scenarios other than those involving only S and T procedures. In what other situations should we use –25?
 

A:  The definition of modifier -25—Significant, Separately Identifiable Evaluation and Management Service…on the Same Day of a Procedure or Other Service—has not changed. The OPPS final rule for 2009 included no changes pertaining to use of this modifier. The CMS transmittal for the OCE update states:

Under some circumstances, medical visits on the same date as a procedure will result in additional payments. A modifier of 25 with an Evaluation and Management (E&M) code, status indicator V, is used to report a medical visit that takes place on the same date that a procedure with status indicator S or T is performed, but that is significant and separately identifiable from the procedure. However, if any E&M code that occurs on a day with a type “T” or “S” procedure does not have a modifier of 25, then edit 21 will apply and the claim will be returned to provider.

These are the same guidelines that have been in place.  



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