Dermatology Coding Alert

Published on Sun Jun 11, 2006 PDF

Question: I'm always at a loss on whether to use modifier 25 or modifier 57 when the dermatologist unexpectedly finds the need to do a biopsy of a minor growth during a consultation E/M. What is an example of when these individual modifiers are appropriate?

Oregon Subscriber

Answer: Modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 57 (Decision for surgery) are easily confused, but the distinguishing factor is that Medicare restricts modifier 57 to major surgeries.
 
So, if you go with your example in which the dermatologist performs a regular E/M and decides to remove a minor growth, even though it's a "surgery" you should use modifier 25 on the E/M (and report the biopsy code as well).
 
Example: A new 67-year-old female Medicare patient comes in for a consultation because she's concerned about a growth on her left arm. The dermatologist does a full history and exam and decides to perform a biopsy. In this case, you would report 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) and 99243-25 (Office consultation ...).
 
If you're wondering how to distinguish between a "major" and a "minor" surgery, look at the global period. If it's zero, you shouldn't even consider modifier 57. Reserve modifier 57 for major surgeries, in which the global period is 90 days -- but make sure the surgery wasn't prescheduled, or you'll be looking at a denial.
 
Check with your private payers for their rules, but know that many of them mirror what Medicare says on this issue.
 
Tip: Now more than ever before, you should watch your modifier 25 usage, because the OIG recently released a major audit report that revealed frequent misuse.