Revenue Cycle Insider

Question: Do I need to append modifier 25 every time I report an evaluation and management (E/M) service along with a minor procedure?

Florida Subscriber

Answer: 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 one of the most frequently misused modifiers in coding scenarios like the one you describe. To decide whether the modifier applies, you’ll need to first ask if the practitioner performed a significant, separately identifiable E/M service beyond the work normally included in the minor procedure. If the additional evaluation stands on its own and is supported by the documentation, reporting a separate E/M service along with modifier 25 may be  appropriate.

Make note: Minor procedures with a 0-day or 10-day global period already include an E/M component, which covers the routine evaluation, decision making, and care associated with the procedure. Because this work is built into the procedure’s relative value units (RVUs), you won’t normally report a separate E/M service.

However, if the practitioner evaluates a significant, separately identifiable problem that requires work beyond the usual care related to the procedure, you may report a separate E/M service along with modifier 25. For example, if a patient undergoing a minor procedure also receives an evaluation for an unrelated sports injury, you may bill the E/M service separately when the documentation supports the additional work.

Stay tuned: The Centers for Medicare & Medicaid Services (CMS) has proposed reducing payment for office or outpatient E/M visits reported with modifier 25 when they are performed on the same day as a procedure with a global period. Under the proposal, the highest-valued service would be paid at 100 percent, while additional same-day services provided by the same physician or group practice would be paid at 50 percent. CMS says the change is intended to account for any overlapping work and avoid duplicate payment. The final decision is expected in November.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC