EM Coding Alert

Find out what information you need to append modifier 25 correctly and with confidence.

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is a great tool for securing earned payment, but commercial and government payers are scrutinizing its use and crying misuse and overpayment.

Jacob Swartzwelder, CPC, CIC, CRC, CEMC, CPMA, shared insights on how to use modifier 25 correctly in his AAPC AUDICTCON 2025 presentation “Modifier 25: Medical Necessity & MDM.” Last month we covered some documentation and problems addressed — keep reading for more information on how to evaluate encounter data and management.

Evaluate Data on These Merits

When you’re evaluating how data plays into evaluation and management (E/M) leveling or modifier necessity, think about how data is an important element of a provider’s thought process.

Consider an emergency department (ED) encounter, Swartzwelder suggested. “A lot of times we’ll have things ordered out of standing order only,” he said. Like if a patient comes in with chest pain, the physician will probably order chest X-rays, perform an electrocardiogram (EKG), and check troponin levels. When considering modifier 25, coders want to look at the documentation to see which labs were actually considered in the formulation of a treatment plan, not just which labs were ordered and reviewed.

“That’s where we want to make sure there’s a direct impact on that data point that we’re pulling out of a study or some sort of testing. It has to be utilized in that thought process during the day that we’re billing that evaluation and management encounter,” he explained. “We want to make sure that anything ordered or reviewed is relevant.”

If a patient comes in with back pain and gives the physician a disc with images, the provider may look at it but not use any of the information for the actual treatment plan, he said.

“What we want to see in documentation is a link between why that review was important, what it led to, what it told us — an actual interpretation of how that result is going to help us go somewhere,” he said. “It doesn’t have to be a lot of text, but it has to be something that’s relevant and shows that the information is being directly used to initiate a thought process. If we have unrelated or routine data elements, it’s a really weak justification.”

Consider an Auditor’s Perspective

Sometimes a provider’s use of data isn’t unclear or ambiguous, but reporting the data interpretation correctly is heavily reliant on how it’s presented in the documentation, Swartzwelder said.

He shared that he personally believes that data may be a less useful element of consideration when leveling E/M, because it doesn’t provide as much evidence to stand upon.

“I feel much more confident in arguing an E/M level based on problems and risk than I do on data,” he said.

He pointed to the major changes to E/M released in 2021 and 2023 and said that documentation hasn’t necessarily kept up with the changes, brewing a lot of misinformation because coding teams, billers, auditors, and payers aren’t necessarily on the same page.

 “That’s why I tend to consider it a little higher risk option to build out my E/M. But to get to that moderate level, we do want to see substantiated data there,” Swartzwelder said.

Look At Risk, Too

Risk applies to three different areas of coding, Swartzwelder said. There are risks inherent to a procedure, risk related to concern, and risk that is part of the medical decision making (MDM) table, which involves the risk that the provider considers for the treatment plan they’ve selected.

Inherent risks to procedures are already bundled, he said. To meet the criteria for a separate E/M service for a procedure, the provider would need to perform additional management regarding risk. For example, if the provider is prescribing a steroid to a patient who has diabetes, there may be a concern that the steroid would have an impact on the diabetes.

“If we’re going to think through a process for that after this procedure, and maybe even do something preventive with a systemic medication or something like that, we’re in territory of having that separate thought process that we need to capture with MDM,” he said. This could be grounds for appropriate use of modifier 25.

You can apply a similar approach to comorbidities. If a procedure is going to impact a chronic condition, and the provider adjusts the treatment plan for the chronic condition for a limited period of time, then an additional, separate E/M service may be involved.

Remember this: Swartzwelder recommended coders ask themselves this question when figuring out whether to append modifier 25: “Would the patient have come in for this service separately if they weren’t already here?”

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC