Five for Modifier 25
Five steps is all you need for modifier 25 claim success.
By G. John Verhovshek, MA, CPC
Misuse of modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service is among the most common coding mistakes, costing medical practices millions each year in missed reimbursement opportunities and costing insurers millions each year in improper payments. You can improve your chances for modifier 25 success if your claims meet the following five criteria.
1. The physician must provide an evaluation and management (E/M) service and a separate procedure or service for the same patient on the same day.
Do not apply modifier 25 if the physician performs an E/M service only.
For example, a neurologist examines a patient experiencing upper-extremity weakness and pain. After a thorough examination, the physician schedules the patient for a diagnostic electromyography (EMG) exam to follow several days later.
In this case, you would report an appropriate outpatient E/M code, such as 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. . Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family, depending on the documented service level. Because the neurologist provided only the E/M service on the initial service date, modifier 25 is not appropriate.
For electrodiagnostic testing on a later service date, you would report the appropriate EMG code, such as 95861 Needle electromyography; two extremities with or without related paraspinal areas. Unless the patient experiences a significant worsening of symptoms or a new complaint requiring a separate evaluation, you would not report another E/M service for this later encounter.
Note that all physicians who bill under the same National Provider Number (NPI) (such as physicians sharing an NPI in group practice) are considered, from a coding perspective, the same provider.
2. The same-day E/M service must be significant and separately identifiable.
According to CPT® and the Centers for Medicare & Medicaid Services (CMS) guidelines, all procedures and services—no matter how minor—include an inherent E/M component. Any E/M service you report separately must exceed the minimal evaluation that normally accompanies any other same day service(s) or procedure(s).
CMS Transmittal 954 (Medlearn Matters MM5025, Change Request 5025, May 19, 2006) states specifically you should apply modifier 25 only for “a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work for the service.”
A significant, separately identifiable E/M service might occur on the same day as another procedure or service when:
1. The provider sees a new patient, or
2. The provider sees an established patient with a new complaint or a change in status.
In either case, a separate E/M service is essential to determine the need for any same-day procedure(s) or service(s) that follow.
For example, an orthopedist sees a new patient for knee pain evaluation. The orthopedist diagnoses the patient with osteoarthritis of the knee and discusses options for management, then injects a steroid such as Depo-Medrol (J1020 Injection, methylprednisolone acetate, 20 mg or J1030 Injection, methylprednisolone acetate, 40 mg) to provide patient relief.
You may report both the aspiration and the same-day E/M in this case using 90772 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular and 99201-99205, as appropriate to the documented E/M service level, with modifier 25 appended. You may also report the drug supply. Only after completing an E/M service would the surgeon make a decision to perform an additional procedure (the injection).
In a second example, a consult patient visits a cardiologist complaining of palpitations (785.1 Symptoms involving cardiovascular system; palpitations) and light-headedness (780.4 General symptoms; dizziness and giddiness). The physicians performs a complete cardiac workup (for example, 99243 Office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family) and orders a same-day, in-office echocardiogram.
You may report both the echocardiogram and the same-day E/M in this case, using 93307 Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete and 99243-25. You might also report additional codes, such as +93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete (list separately in addition to codes for echocardiographic imaging) or +93325 Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiography), depending on the equipment and the images the physician obtained. Only after completing an E/M service would the physician make a decision to perform additional procedures (in this case, the echocardiography).
If the provider sees the patient for a previously-scheduled procedure or service, you would not normally report a separate, same-day E/M service. “Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed,” confirms the Medicare Claims Processing Manual (Chapter 12, Section 40.1).
In our first example, the orthopedist would not claim an E/M service on the same day as the previously-scheduled injection. Remember: The physician has already evaluated the patient for the same problem during the earlier E/M visit. The orthopedist may provide a cursory exam immediately prior to the injection, but such an evaluation is neither significant nor separately identifiable. Rather, it is an inherent component of the injection itself.
Even if the physician provides an assessment and plan, you probably should not report a separate E/M service unless the patient has a new, unrelated complaint, or has experienced a worsening of symptoms that prompt a new history, exam, and medical decision-making (MDM).
Documentation should support unambiguously any separately-reported E/M service. Explanatory text for modifier 25 in the CPT® manual stresses “a significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service” you choose to report. CMS rules also stress that the provider must “appropriately and sufficiently” document medical necessity for both the E/M service and the other service or procedure. Although you don’t need to submit this documentation with the claim, it must be available upon payer request.
Physicians can help highlight a separate E/M service by separating the E/M service documentation from any other same-day procedure(s) or service(s) documentation. That is, the provider should document the history, exam, and MDM in the patient’s chart, and record the procedure notes on a different sheet attached to the chart or in a different section within the electronic medical record. This demonstrates to the payer and the coding staff the distinct nature of the E/M service.
At a minimum, providers should document same-day E/M services as well as if they had not provided any other procedure(s) or service(s).
3. The E/M service doesn’t take place during a global period.
All related, follow-up examinations by the same physician during a previous procedure’s global period—such as those to evaluate the patient’s recovery—are included in the global surgical package of the previous procedure.
For an unrelated E/M service during a previous procedure’s global period, you may report an appropriate E/M code with modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period appended. This would require that the E/M service is for a new problem not connected to the patient’s previous complaint or procedure.
4. The same-day procedure(s) or service(s) does not have a 90-day global period.
You should append modifier 57 Decision for surgery—not modifier 25—to a separately identifiable E/M service occurring on the same day, or on the day before a major surgical procedure, and resulting in the physician’s decision to perform the surgery, according to the Medicare Claims Processing Manual, section 40.2.
A major surgical procedure is any procedure or service with a 90-day global period. Note that the global period for a major surgical procedure begins one day prior to the actual procedure.
For example, a neurosurgeon in the ED examines a patient with a closed-in head injury due to a fall. Upon full evaluation, the surgeon admits the patient and immediately operates to evacuate a subdural hematoma (61108 Twist drill hole for subdural or ventricular puncture; for evacuation and/or drainage of subdural hematoma).
In this case, you should report both the surgical procedure (61108) and the examination that led to the decision to perform the surgery (such as 99284, Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. ).
Because the evacuation is a major procedure (it has a 90-day global period), you should append modifier 57 to 61108. The available documentation should note specifically that the E/M service resulted in the decision for surgery.
You can find global periods for all CPT® procedure codes by consulting Medicare’s Physician Fee Schedule relative value file (MPFS RVU), which you may download from the CMS Web site..
Be sure to select the most recent file for download as it is updated quarterly.
To determine the global period for a particular procedure, simply look to the fee schedule’s “GLOB DAYS” column. You will find several categories, including 000 (zero), 010, 090, XXX, ZZZ, YYY, and MMM (for maternity codes).
Note that carriers may classify as “major” some procedures with a “YYY” global period. Check with your carrier before reporting an E/M service modifier with these procedures.
5. Provide a diagnosis for the E/M
You do not need a separate diagnosis to justify a same-day E/M service with modifier 25. CPT® specifically states, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.” CMS guidelines, as articulated by Transmittal 954, uphold this instruction.
For example, a new consult patient visits a general surgeon with a complaint of intense heartburn and abdominal pain. The surgeon takes a complete history and performs an extensive exam. She then performs diagnostic endoscopy to check for reflux disease.
In this case, you will report the endoscopy with 43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure). Separate documentation will also support a level-three outpatient consult, with modifier 25 appended (99243-25).
You should link the signs and symptoms that prompted the exam (787.1 Heartburn and 789.00 Abdominal pain; unspecified site) to the E/M code. You can link the same signs-and-symptoms diagnoses to the endoscopy. Or, if the surgeon finds verifiable evidence of reflux disease (530.xx), you would report that diagnosis as primary.
If you can cite a different diagnosis for the E/M service, such as when a patient arrives for a scheduled procedure but the physician must provide E/M for a new, unrelated problem, be sure to link a separate diagnosis to the E/M service, to show it is an independent service.