Health Information Management

Tip: Consider intent of visit when appending modifier -25

APCs Insider, April 22, 2011

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Coders need to look at the intent of the visit when determining whether to append modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

Don’t assign an E/M code with modifier -25 if a patient presents specifically for a procedure or service, and the provider does not perform a separate E/M service beyond those necessary for that procedure.

When a patient makes an appointment for an E/M, it is usually just an office visit. The medical staff could be reviewing medications, checking the patient's blood pressure, or performing an annual physical.
A patient may present for the evaluation of an injury or illness and the physician also performs a procedure during the visit.

Consider this example. A 46-year-old male presents to the ED for evaluation after a minor traffic accident. According to the facility's guidelines, the physician performs a level four ED service. During the visit, the physician determines that the patient requires a simple repair of a 1.7-cm facial laceration.

In this case, the coder can report a separate E/M service. Coders should report 99274-25 for the level four ED visit and 12011 for the simple repair of the superficial facial wound.

The tip is adapted from “Significant, separately identifiable E/M: Modifier -25” in the April issue of Briefings on APCs.

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