Health Information Management

Q&A: Follow CMS' coding guidelines when using modifier -25

APCs Insider, August 1, 2008

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QUESTION: Are there any guidelines with respect to the appropriate use of modifier -25 for hospital outpatient reporting? It is my understanding that, for Medicare, we should always append modifier -25 to the facility emergency room (ER) evaluation and management (E/M) codes whenever we bill a procedure with a status indicator of ?S? or ?T? on the same date of service. What about the other outpatient evaluation E/M codes? Should we always append modifier -25?
ANSWER: CMS has cautioned hospitals that use of modifier -25 must meet coding guidelines when used in hospital emergency or other outpatient departments. Hospitals use modifier -25 to distinguish E/M services that are significant and separately identifiable from a procedure or other service performed on the same day.
In a Program Memorandum (A-00-40) released at the inception of OPPS, CMS provided guidance on what is considered a significant and separately identifiable visit in a hospital outpatient department. While CMS does not require a separate diagnosis for the E/M service, the services must be more than measuring blood pressure, taking temperature, asking the patient how they feel, or getting a consent form signed. CMS considers these to be part of the outpatient procedure that the physician performs. The modifier description states that to be significant and separately identifiable, the services must be above and beyond the other services provided, and specifically beyond the usual preoperative and postoperative care associated with the procedure.
In that same Program Memorandum, CMS does instruct hospitals to report modifier -25 for all ER visit codes when they report them with any diagnostic or therapeutic medical or surgical procedure. However, CMS subsequently published guidance that limits the use of modifier -25 to situations where the procedure that hospital staff provide with the visit has a status indicator of ?S? or ?T? and where the ER visit meets coding guidelines for the use of modifier -25 (i.e., is significant and separately identifiable). 
Specifically, Medicare published Frequently Asked Question (FAQ) 2389 in 2003, updated in July of this year, instructing hospitals on use of modifier -25 in the ER. In that FAQ, they indicate that modifier -25 may not be used for all small laceration repairs in the ER, but rather should only be used when the hospital provides significant and separately identifiable E/M services above and beyond the other services provided. This clearly indicates that there may be some visits to the ER where an E/M visit code and modifier -25 would not be appropriate. Each facility must evaluate the practices in their own ER. Do not bill visits that are specifically for a procedure and where the facility does not provide a significant separately identifiable E/M service using an E/M code or with modifier -25.
Next week, in response to a separate reader question, we?ll address the specific application of modifier -25 in hospital outpatient wound care facilities.

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