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Internal Medicine Coding Alert

Modifier -25 Know the Conditions for Its Use

Published on Sat Sep 01, 2001 Print Friendly and PDF PDF

Internists must understand that proper use of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) will directly affect payment, according to Stephanie Jones, NRCMA, NRAHA, CPC, director of audit programs for eCompliance Doc. Modifier -25 instructs the carrier to reimburse a particular E/M service along with a separately performed procedure.
 
"A lot of times the internist is not aware of exactly when to use modifier -25," Jones says. "The biggest benefit to physicians is that they don't need to have two separate diagnosis codes."
 
Previously, some payers would reimburse for an office visit and procedure on the same day only if each had a distinct diagnosis. In 1999 CPT redefined the use of modifier -25 stating that diagnoses no longer have to be different because the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.
 
The challenge is to show that an E/M was separate from a procedure, Jones says. Although many carriers interpret "separately identifiable service" to mean "unrelated" to the service performed, HCFA (now CMS) adopted a memo written in June 1992 by the then-director of the Bureau of Policy Development to all associate regional administers for Medicare stating, "A documented, separately identifiable related service is to be paid. We would define related as being caused or prompted by the same symptoms or conditions."
 
Now, only when an internist furnishes a significant, separately identifiable E/M service before providing a procedure with a 0- or 10-day global period may the E/M service be paid in addition to the procedure. To indicate that the E/M service is not related to the surgical procedure, append modifier -25 to the E/M service code.

How To Identify a Separate E/M Service
 
Medical necessity must drive the work performed, Jones says. "Carriers want to be sure that the E/M service was distinct and any procedure was work above and beyond what is conducted in a regular office visit," Jones says. "The rule of thumb is if the patient medical complaint requires the doctor's medical expertise, then chances are modifier -25 is required." If the internist provides a service that translates to "just good medicine," modifier -25 is probably not needed.
 
For instance, a patient presents with knee pain. After a complete workup, the internist arrives at a diagnosis for osteoarthritis (715.16) and decides to treat the problem with a three-part injection series (90782-90784). The doctor can legitimately bill separately for the injection series and the office visit by appending modifier -25 to the appropriate E/M code. Because the physician did not know the treatment plan prior to the exam, he or she is justified to bill separately for the E/M service, i.e., the E/M service was necessary to determine the need for the procedure.
 
Jones says a simple laceration suture is one of the few exceptions when the physician may not know the reason for the visit but the service provided is obvious and, therefore, applying modifier -25 to the E/M service is inappropriate. Because only the repair is necessary, and there is no need for a separate evaluation, it alone should be billed.
 
However, "If the patient presented with a laceration to the head and the physician needs to evaluate the patient for head trauma, it would be appropriate to apply modifier -25," Jones says.

E/M Service Must Also Be Significant
 
According to Charlotte Price, RHIA, CPC-P, coding specialist for the Brody School of Medicine in Greenville, N.C., the internist must perform a full workup that results in a decision to perform a procedure before coding an E/M with modifier -25. In most cases, she says not to use modifier-25 if a patient presents for a previously scheduled, planned procedure.
 
"Sometimes doctors perform a brief visit the same day as a scheduled procedure and most do not include an exam or take a history," Price says. "In that case, they cannot use an E/M code with the -25 modifier in addition to the procedure for the visit. That brief encounter with the patient really is part of the procedure."
 
For example, if the internist sees a patient and schedules a procedure for another day, there is no E/M to be charged on the day of the procedure unless the patient has another major complaint that needs to be examined. "The biggest improper use of modifier -25 is when someone is scheduled for a procedure and the E/M is billed too," Price says.
 
An example of the improper use of modifier -25 is when the internist asks the patient only a few brief questions during a scheduled lesion excision. On the other hand, Price says, if the physician decides to leave the lesion alone unless it bothers the patient -- and the patient returns later to have the internist take a fresh look at the problem before deciding to perform the excision -- an E/M visit with modifier -25 can be coded.
 
Price advises physicians to keep E/M notes separate from the procedure note in the chart. Physically separating the documentation makes it easier to appeal denials, she says. Doctors tend to throw the procedure notes into their exam notes particularly when billing an E/M with a diagnostic procedure. This can make it difficult for carriers to distinguish between the procedure and the E/M exam.
 
Coders should also make sure the patient is not already in a global period from a previous procedure performed within the last 10-90 days. Pride adds that for preoperative critical care codes billed on the date of the procedure, make sure the diagnosis supports that the service is unrelated to the performance of the procedure. In other words, the patient requires critical care (regardless of whether the procedure was ever done).
 
A carrier can conduct a specific medical review on the use of modifier -25. If, after reviewing the data, it determines that the use of modifier-25 exceeds the usual amount recorded by most internists, the carrier may impose prepayment screens or documentation reviews.

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