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Tip: Take these actions to ensure correct use of modifier -25

APCs Weekly Monitor, July 9, 2010

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Modifier -25 indicates a “significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service,” according to the 2010 CPT Manual Professional Edition, p. 529.

Use of modifier -25 requires that the E/M service be above and beyond the usual pre-/post-operative services integral to the procedure. Ensure correct use of modifier -25 by doing the following:

• Conduct an education session to discuss different scenarios when an E/M with modifier -25 would and would not apply. Ensure that anyone responsible for charging the E/M and assigning modifier -25 understands the rules and knows where to go with questions before billing.
• Discuss documentation improvement with nurses and physicians to address modifier -25 questions. There may be circumstances in which an E/M would be appropriate if the documentation could support it. Ensure you are not appending modifier -25 automatically or arbitrarily and be sure documentation to support it actually exists.
• Know whether modifier -25 is built into your chargemaster and understand the risks of this approach. If you leave the modifier attached, a certified coder should review the claims and remove the modifier before billing when its inclusion is inappropriate.
• Perform a random audit of previous claims to identify any problem areas; then post education and perform concurrent and post-billing audits to identify areas for improvement.
• Watch for OIG reports, CMS articles, RAC issues, and MAC audits that allude to a potential modifier -25 problem. Be aware and stay prepared.

This tip is adapted from “Modifier -25: Is That E/M Service Really Above and Beyond the Norm?” in the July issue of Briefings on APCs.

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