Health Information Management

Use caution when applying modifier -25

APCs Insider, November 19, 2004

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Use caution when applying modifier -25

QUESTION: I'm looking for guidance when modifier -25 is appended to the 99281-99285 E/M code series. Is 99291 used if the separately identifiable procedure performed at the same visit has an S or T status indicator?

If other procedures without a status indicator S or T such as 90784, 90780, 90471, 90782, 90788, or 36415 are performed along with E/M codes 99281-99285, should we NOT use modifier 25?

ANSWER: According to CMS Program Memorandum A-01-80, the OCE requires modifier -25 with E/M codes reported with a procedure code assigned status indicator S or T. However, this edit does not preclude appending modifier -25 to E/M codes reported with procedure codes assigned to status indicators other than S or T. But note the procedure must always meet the definition of significant, separately identifiable service. This applies to hospital services, not the professional component of billing.
The use of E/M code 99291 (critical care) is based on whether the patient meets the definition of a critically ill or injured patient as described in the code. The 30 minute requirement does not have to be met for the hospital to correctly code 99291. The status indicator for 99291 (APC 0620) is "S," for significant procedure. It is not a Status Indicator "V," for visit. But it is an E/M code, so NCCI edits do not apply. This is another reason why the use of modifier -25 is best limited to those situations when other S or T procedures are also performed.

Finally, keep in mind the extra focus paid to modifier -25 in the OIG 2005 Work Plan. To quote from that source, "We will determine whether providers used modifier -25 appropriately. In general, a provider should not bill evaluation and management codes on the same day as a procedure or other service, unless the evaluation and management service is a significant, separately identifiable service from such procedure or service. A provider reports such a circumstance by using modifier -25. In 2001, Medicare allowed over $23 billion for evaluation and management services. Of that amount, approximately $1.7 billion was for evaluation and management services billed with modifier -25. We will determine whether these claims were billed and reimbursed appropriately."

With the OIG paying extra attention to modifier -25, providers whose software automatically appends -25 to an E/M code should use caution.

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