Health Information Management

Modifier -25: Is that E/M service really above and beyond the norm?

JustCoding News: Outpatient, July 14, 2010

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A patient comes into your outpatient facility for a minor surgical procedure and the physician evaluates the patient before performing the procedure. Should you append modifier -25 for the evaluation and management (E/M) service?

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.

To use modifier -25, “the E/M service must be above and beyond the usual pre-/post-operative services integral to the procedure,” says Debbie Mackaman, RHIA, CHCO, regulatory specialist at HCPro, Inc., in Marblehead, MA.

The CPT codes for minor surgical procedures include preoperative evaluation services, such as assessing the site or problem, explaining the procedure and risks and benefits, and obtaining the patient’s consent. In Chapter 12, Section 40.1 of the Medicare Claims Processing Manual, CMS clarifies that the initial evaluation is always included in the reimbursement for a minor surgical procedure, so it is not separately billable.

In general, when applying modifier -25 to an E/M code, the procedure should have a status indicator of S (significant procedure, not discounted when multiple) or T (significant procedure, multiple reduction applies). But CMS will sometimes accept modifier -25 on an E/M code when paired with procedures that have status indicator X, says Sarah L. Goodman, MBA, CPC-H, CCP, FCS, president/CEO and principal consultant at SLG, Inc., in Raleigh, NC. When in doubt, check with your local FI or MAC.

“You just want to be sure the E/M with the modifier -25 isn’t the only line item on the claim because then you will have an edit,” Goodman says.

When to append modifier -25

According to CMS, you can append modifier -25 only to E/M service codes within the range of:

  • 92002–92014 (ophthalmological services)
  • 99201–99215 (office or outpatient services)
  • 99281–99285 (ED services)
  • 99291 (critical care services)
  • 99241–99245 (office or other outpatient consultations)

You may also use modifier -25 with HCPCS codes G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) as well as G0175 (scheduled interdisciplinary team conference [minimum of three exclusive of patient care nursing staff] with patient present).

The same physician/practitioner does not have to perform the procedure and the E/M service in order for modifier -25 to apply in the facility setting. What is important is that the same facility provided the procedure and the E/M service.

Determine the intent of the visit before making the decision to assign an E/M code with modifier -25, Goodman says. If a patient presents specifically for a procedure or service and no separate E/M services are provided beyond those necessary for the procedure, do not assign an E/M code or modifier -25. If a patient is presenting for the evaluation of an injury or illness and just happens to have a procedure or service during the visit, then it is appropriate to assign an E/M code with modifier -25.

Although coders and billers often assign the E/M level first and then code the procedure, they should approach it in reverse, Mackaman says. The coder should code the procedure first, which includes any interventions that are part of that procedure’s pre- and post-operative work. Then if any additional work exists outside of the procedure, the coder can appropriately assign an E/M code with modifier -25.

Know the coding rules

One reason modifier -25 is used improperly is that whoever assigns the modifier may not completely understand the CPT definition and CMS’ guidance on its use, Mackaman says.

Consider the following two examples:

Example 1: A healthy male presents to the provider-based clinic after cutting his finger on a knife in the kitchen (a relatively clean environment). The patient has no known medical conditions, is not on any medications, and has no other complaints. A nurse assessed and cleaned the wound, and the physician performed a simple laceration repair (CPT code 12001). The wound was dressed and the nurse provided routine discharge instructions.

Prior to assigning the E/M but after assigning the procedure code, the coder should ask: Is this outside of the usual pre-/post-operative work for the laceration repair, and are there significant and separately identifiable E/M services?

“In this case, there most likely is not any additional work and only the procedure should be billed,” says Mackaman.

Example 2: A male presents to the provider-based clinic after falling and cutting his finger on a knife in the barn. The patient has type II diabetes, hypertension, past history of a cerebrovascular accident, and complained of being dizzy and nauseous prior to the fall that caused the laceration. The nurse took a detailed medical history as well as a detailed medication review. The nurse then assessed and cleaned the laceration, and the physician performed a simple laceration repair (CPT code 12001).

In addition to the laceration repair, the physician ordered lab and a head CT, which were normal. The wound was dressed and the nurse provided detailed discharge instructions, including a prescription for antibiotics based on the dirty environment where the laceration occurred.

After assigning the procedure code but prior to assigning the E/M, the coder should ask: Is this outside of the usual pre-/post-operative work for the laceration repair, and are there significant and separately identifiable E/M services?

“In this case, the answer is yes, and both the procedure and an appropriate level of E/M service with modifier -25 and any other ancillary services should be billed,” Mackaman says.

To ensure correct use of modifier -25, take the following actions:

  • Hold an education session to discuss different scenarios when an E/M with modifier -25 would and would not apply, Mackaman says. Make sure that anyone responsible for charging the E/M and assigning modifier -25 understands the rules and knows where to go when he or she has questions, prior to 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. Remember those old sayings of “What are you thinking?” and “If it’s not documented, it didn’t happen.” “You want to ensure that modifier -25 is not appended automatically or arbitrarily,” says Goodman. “Be sure the documentation actually exists to support it.”
  • Know whether modifier -25 is built into your chargemaster, and understand the risks of this approach. If the decision is made to leave the modifier attached, have a certified coder review claims and remove the modifier prior to billing when it 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 Office of Inspector General (OIG) reports, CMS articles, Recovery Audit Contractor issues, Medicare Administrative Contractor audits, etc., that allude to a potential modifier -25 problem. Be aware and stay prepared.

The OIG has already released one report on the use of modifier -25. In its 2005 report, Use of Modifier 25, 35% of the claims it reviewed failed to prove an E/M was appropriate in addition to the procedure, resulting in overpayments of $538 million.

That high failure rate should have gotten the attention of all providers—hospitals and physicians, Mackaman says. The OIG recommended that CMS work with carriers to reduce the errors and also stressed that CMS should work with providers to make sure they understand the correct application of modifier -25.

The report may be five years old, but it’s still relevant. “After the OIG has reported on an issue, it does not mean that that topic should drop off anyone’s radar,” Mackaman says. In fact, she adds, it should remain on the radar so that providers continue to verify that they are meeting the rules—becoming part of the education routine and auditing as necessary.

This article was originally published in the July issue of Briefings on APCs. E-mail your questions to Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.



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