Receive Proper Payment:
Distinguish Between Using Modifier -25 for ED Facility Versus Professional Service
Published on Sat Sep 01, 2001
Although the advent of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for hospital billing in June 2000 promised greater reimbursement for emergency facilities, it also created confusion among ED coders. Because rules for modifier -25 in a facility setting (hospital services only) differ from those on the professional side (physician services only), the main challenge is knowing when to append it to an E/M service. CMS has released two new transmittals to clarify the issue.
Transmittal A-00-40, released July 20, 2001, states that Medicare requires that modifier -25 "always be appended to the emergency department E/M codes when provided on the same day as a ... procedure." The Outpatient Code Editor (OCE) only requires modifier -25 on an E/M code when it is reported with a procedure code that has a status indicator of "S" (significant hospital procedures not subject to multiple procedure discounting) or "T" (significant services subject to multiple procedure discounting, usually surgical procedures). But the edit does not preclude appending modifier -25 to E/M codes with other procedure codes, as long as the E/M is significant and separately identifiable.
"The real difference in using modifier -25 for facility billing versus professional billing seems to be with diagnostic testing," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates Ensuring Optimum Reimbursement for Emergency Physicians in Oklahoma City. The physician cannot bill for the test but may bill for the interpretation of the test, he says. "The modifier applies for physicians when performing services that are significant and separate from the procedure."
For facility billing, the diagnostic (with the exception of pathology and laboratory) and/or therapeutic procedure code ranges 10040-69990, 70010-79999 and 90281 include taking the patient's blood pressure and temperature, asking the patient how he or she feels and getting the consent form signed. The E/M service is built in to these procedures, so do not bill for it separately.
Sometimes, however, it is appropriate to report an E/M service in addition to the procedures provided on the same date, if the key components (history, examination and medical decision-making [MDM]) call for a higher level.
Modifier -25 should be appended only to facility E/M service codes within the ranges 92002-92014 (general ophthalmological services) and CPT 99201 - 99499 , and to HCPCS codes G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) and G0175 (scheduled interdisciplinary team conference [minimum of three exclusive of patient care nursing staff] with patient present) when performed with any procedure from 10040-69990, EKGs, radiological procedures and medicine codes 90281-99xxx (exclusive of E/M services).
The OCE will continue to process claims for those procedure codes that are [...]
