use of 25

[dezinez1980]

hello, my co workers and i are trying to figure out the correct usage of modifier 25.

scenario 1
pt presents for bump on leg, provider decides to to I&D for cellulitis.
we have agreed this qualifies for mod 25 since pt presented with "bump" and procedure was decided on when provider did examination.

scenario 2
pt presents for sore throat, runny nose and chills. provide does strep test, results are positive. she also mentions period missed last month, she would like a pregnancy test.
i do not feel this is significant enough to require a 25, but coworker feels that because test was not part of visit initially, 25 should be added.

are both correct times to use 25? please help!

[laureenj]

It sounds like in both of these cases the patient came in for an EM service and after that was provided the physician decided to do a procedure. I would code the EM with mod 25 in both cases and then the procedures of course.

When I teach about modifier 25 I ask my students to visualize the report - if they can see a clear History, Exam and MDM (HEM) in addition to notation relative to the procedure they are good to bill the EM.

So the rhyme is "If you don't have a HEM you can't bill an E&M"

That is what they mean by "separate and significant". If all you see when you read the note is all about the procedure then you don't have a separate or significant EM service. Every procedure has a mini-EM built into it. For example - if a patient is scheduled for an I&D and comes in for it the physician usually doesn't do a full EM (because that was usually done at the previous visit) but they do assess the area before cutting into it - they make a decision as to how to cut, how to dress the wound, etc. That mini-EM if you will is bundled into the procedure code.

So the payer is assuming when they see a procedure code and an EM on the same DOS that the EM is bundled into the procedure unless you put modifier 25 on and that tells them - this is not the mini-EM that's usually bundled - this is a SEPARATE EM service and it's SIGNIFICANT because I have HEM documentation to prove it.

Does that help?

[mcnaryk]

Originally Posted by dezinez1980

hello, my co workers and i are trying to figure out the correct usage of modifier 25.

scenario 1
pt presents for bump on leg, provider decides to to I&D for cellulitis.
we have agreed this qualifies for mod 25 since pt presented with "bump" and procedure was decided on when provider did examination.

scenario 2
pt presents for sore throat, runny nose and chills. provide does strep test, results are positive. she also mentions period missed last month, she would like a pregnancy test.
i do not feel this is significant enough to require a 25, but coworker feels that because test was not part of visit initially, 25 should be added.

are both correct times to use 25? please help!

Scenario 1 = yes, that would be correct. Scenario 2 = no. Modifier 25 is usually appended to the E/M code when a procedure is also done during the same visit. An I & D would count, a pregnancy test would not. I hope this helps!

[impala72]

I have an issue.I wokr in a cancer center with physician billing and outpatient billing. Patient was seen by physician with regular E&M visit, that same day same place patient had a spinal tap done. I was going to use modifier 25 but, there were other items noted in the 59 modifier that could also be used. ( I am still new at coding)

[DGRAF]

In this instance you would use the -25 on the E&M. -59 is used for multiple procedures.

[jbrightw]

If any billable procedures done along with an E/M on the same DOS by the same physician, you should use 25 modifier even if the procedure done is related or unrelated to the reason for the visit, otherwise it is not significant and separate from the E/M.

59 cannot be used with E/M, but it can be used with the smaller procedure when two or more distinct procedures have been done which are bundled.

Hope it helps.

Brightwin