EM Coding Alert

Make sure you can survive a modifier 25 audit with these tips.

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 an important tool to secure payment, but coders who use it inappropriately risk trouble. In May, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) released audit findings regarding the use of modifier 25 with an eye injection procedure showing high improper payment rates for this procedure and modifier, and, thus, noncompliance with Medicare regulations.

Jacob Swartzwelder, CPC, CIC, CRC, CEMC, CPMA, shared insights on how to use modifier 25 correctly regarding documentation and thought process with medical necessity and medical decision making (MDM) in his AAPC AUDICTCON 2025 presentation “Modifier 25: Medical Necessity & MDM.”

Keep reading for some preliminary information and check back next month for even more tips about how to determine whether it’s appropriate to append modifier 25.

Seek Context on Modifier 25

Modifier 25 is a high-risk modifier according to payers, and one that is often a target during audits. It’s a common source of denials and repayments, and providers who use it may bear scrutiny for double-dipping their evaluation and management (E/M) services. Swartzwelder underscored that if usage of modifier 25 correctly depends on whether the service was truly significant and separately identifiable.

E/M services have built-in components, and codes reflect the comprehensive nature of the services. Even services ostensibly outside the scope of E/M still incorporate some elements, like the history and exam related to the procedure and the thought process behind the decision to perform the procedure.

Swartzwelder shared some tips on evaluating problems addressed to decide if they’re inherent to an E/M service or go above and beyond. Usually, a prescheduled or planned procedure suggests that a problem is already addressed. However, a new or worsening problem brought up during the encounter may justify a separate E/M, but the decision-making should be well documented, and the provider should consider the problem while questioning whether it was newly evaluated or already accounted for.

Consider These Examples of Possibly Appropriate Use

This seems straightforward, but Swartzwelder offered an example: If a patient shows up for chemotherapy, the provider probably needs to evaluate both the patient’s mien and general well-being before starting, as well as the possibility of additional lab work or other tests that might inform treatment or check for contraindications. “There is additional new, above-and-beyond thought process to that planned procedure,” he explained. Such a situation may call for modifier 25.

Another situation where modifier 25 may be appropriate: A patient arrives for their scheduled procedure, but the severity of the condition they’re experiencing has escalated drastically, and the original treatment plan is no longer the best fit. “That is the evaluation and management pause where we’re going to be like, ‘Whoa, I’m not able to just check off and continue. We need to rethink this: I need to either do a different plan or we need to do a more intense procedure,’” he said.

Basically, a prescheduled, preplanned procedure where nothing has changed is probably not in modifier 25 territory; but when a patient has something that’s new, worsening, or escalating, and the provider is pausing to rethink things, then modifier 25 may be appropriate, as you may have a separately identifiable service situation, he said.

Look For These Elements in Documentation

When reporting modifier 25, you need to make sure your documentation is watertight, as payers may already be skeptical of modifier 25 usage and be looking at such claims with extra scrutiny.

For documentation, “we’re going to want to see that there was a concern, which ties back to those identified risks for a problem,” Swartzwelder said.

The documentation needs to clearly identify a condition changing or worsening, and whether or how the provider wants to adjust treatment. “We need to start getting documentation in the record that shows that something is different than our original thought that we already got credit for,” he said.

Look for next month’s article for more information and tips on appropriate modifier 25 usage.

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