Use Modifiers -25 and -G0 Correctly for Proper Reimbursement

Applying modifier -25 is vital to receiving payment for a separate evaluation and management (E/M) service on the same day as a procedure or other service. When the initial service is performed in one department, like the emergency department (ED), and the additional services are performed in another department, such as radiology, you need to know when to apply the -G0 condition code to show when two separate and distinct visits are provided on the same date of service in the same revenue center. Experts offer several solutions to determining this, including running reports and tracking account numbers to make sure you discover these multiple services.

Using Modifier -25

Scenario: A patient presents to the ED, and an E/M service (99281-99285) is performed and billed under revenue center 450. The patient is then sent to radiology for an x-ray (outside revenue center 450). For the hospital to get paid for an ED service when an x-ray is performed in another department, you must use modifier -25. However, the ED coder may not know what transpires in radiology. The computer program for billing does not apply modifier -25 because you cant be sure that the second procedure is always a significant, separate service. Experts agree there is a way to catch when the additional service is performed outside the original revenue center.

Condition Code -G0: Edits Can Help

Some facilities have developed edits to attach a -G0 when there are two unrelated visits within the same revenue center on the same day. This can work, but it gets tricky on the professional fee side, you may have to bundle the resources of the two visits on the same day and bill only one E/M code; on the facility side, you can bill both visits, but must attach the -G0 in the UB92 claim form and enter the number of visits in the units field.

You must have edits on your software to find multiple uses of the same type of code, not just the same code. You could not bill, for example, two E/M levels in the ED for different problems without the -G0 modifier assigned in the appropriate field on the claim form. When multiple visits occur, you are required to enter the number of visits in the units field of the UB92 claim form.

Running a Report

One way to catch these multiple procedures is to generate a report that is run either daily or every 72 hours.

We do have some satellite clinics and different departments so multiple services is an issue here, explains Jan Weins, RHIA, director of medical records at East Texas Medical Center in Athens, Texas. We already had our 72-hour report, which shows [...]

- Published on 2001-02-01