3 Tips Minimize Modifier 25 Mishaps
Published on Thu Jan 19, 2006
Keep your E/M and procedure documentation apart
Every time you fail to report a legitimate, separately identifiable E/M service, your practice misses out on anywhere from $25 to well over $100.
Don't let this happen to you: Here are three tips to help you know when and how to report separate E/M services with modifier 25. Tip 1: Stress -Significance-
To gain payment for an E/M service the physician provides at the same time as another procedure or service, the E/M must be both significant and separately identifiable.
Why you need to be concerned: The Office of Inspector General (OIG) released a report on Dec. 12 that cites widespread misuse of modifier 25 and resulting overpayments by Medicare. The OIG went on to recommend that CMS should -encourage carriers to re-examine their modifier 25 outreach activities and include modifier 25 reviews in their medical review strategies where appropriate.-
All procedures, from simple injections to common diagnostic tests, include an -inherent- E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must be -above and beyond- the minimal evaluation and management that normally accompanies such a procedure, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.
Note, however, that modifier 25 is not restricted to a particular level of service (such as a level-three exam or higher), according to the September 1988 CPT Assistant.
Example: A patient arrives for a previously scheduled diagnostic endoscopy, 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]). The ENT provides a cursory exam to assess the patient's fitness for the procedure. In this case, the level of exam, history and medical decision-making (MDM) are not significant enough to stand on their own as a separate E/M service.
Tip: -I ask myself, -Can I find in the documentation a clear history, exam and medical decision-making beyond a simple -H&P- for the procedure?- If so, I-ve got a separately billable service- with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.
Bottom line: You should consider a brief history and physical prior to a same-day scheduled outpatient procedure as an included component of the procedure itself.
Even if the physician provides an assessment and plan for a scheduled procedure, you probably should not report a separate E/M service unless the patient has a new, unrelated complaint or has had a worsening of symptoms that prompts a new history, exam and MDM process. This would probably include prescribing therapy or ordering other tests unrelated to the procedure. [...]
