Use Modifier -25 to Get Paid for an Emergency E/M Service and a Procedure
Published on Mon Feb 01, 1999
In the emergency department, there are no established patients. Thats why the ED services codes (99281-99285) dont make that a distinction. And obviously, there are no planned procedures in the ED either.
The combination of these two facts should indicate to most emergency physicians that their E/M codes should almost always have the modifier -25 attached if they perform a procedure on a patient after the initial evaluation, says Todd Thomas, CPC, CCS-P, president of the Oklahoma City, OK, chapter of the American Academy of Professional Coders and principal of Thomas and Associates, an emergency medicine reimbursement consulting firm.
No one presents to the emergency department and instructs the physician to splint their broken arm, Thomas states. They come in, the doctor performs an examination and determines a course of treatment, then performs the procedure.
If that is the case, then modifier -25 (significant, separately identifiable procedure performed by the same physician on the same patient on the same day) should be attached to the E/M code. This modifier enables the physician to get paid for both the E/M service and the procedure. If the modifier is not attached, third-party payers often only reimburse one of the codes, usually whichever is less expensive.
However, the modifier is often omitted by ED physicians who dont realize they should be using it, and coders often dont apply it because they dont have the necessary documentation to indicate it should be added.
Ive had several docs say to me that they dont use the modifier if they know just by looking at the patient what is wrong with them, Thomas says. I try to convince them that they performed an evaluation and, even if it is a brief evaluation, they should get paid for that service in addition to [getting paid for] performing the procedure.
Use Modifier -25 on Critical Care Codes
Use of modifier -25 is particularly lacking when critical care E/M codes (99291-99292) are billed, notes Jackie Davis, president and CEO of Term Billing, Inc. an emergency physician group billing company based in Arlington, TX.
Lifesaving procedures such as CPR and intubation often accompany critical care services, she says. But, if these procedures are billed along with critical care codes, often the procedures are not paid for because the modifier -25 is not attached to the E/M code.
Because critical care is time-based and not like the other E/M level codes, many coders dont think the modifiers should be applied, she says. But, Medicare views critical care codes as E/M codes. So coders should always put the modifier on the critical care code to get reimbursed for the procedures.
Note: Modifiers are not always recognized by all third-party payers. Although most larger payers follow Medicare, you should check with the health [...]
