Payer Coommunication Key:
How to Determine When to Use Modifier -25 or -57
Published on Thu Jul 01, 1999
When an otolaryngologist performs a nasal endoscopy (31238) on a Medicare patient who comes in with symptoms of epistaxis (for example, 784.7 or 448.0), he or she typically takes the patients history, does some physical ENT examinations, and then decides the patient needs the endoscopy.
To bill for both the endoscopy and the E/M work, the ENT must file the 31238 and the E/M code (most likely a 99212 or 99213, office or other outpatient visit) with a modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached to the E/M code.
This scenario may appear straightforward, but like so many coding issues, when it comes to reimbursement, there may be complications. Although modifier -25 is appropriately claimed in this instance, many physician practices and carriers are still confused as to how to correctly utilize this modifier, which many consider the most misunderstood and misused modifier ever.
Many ENT offices that OTC spoke with report confusion over when to use -25 or the related modifier -57 (decision for surgery: an E/M service that resulted in the initial decision to perform surgery), and about how commercial carriers, in particular, reimburse either or both claims.
Beth Sutton, a coding and reimbursement specialist in the office of otolaryngologist Paul Antalik, MD, in Pittsburgh PA, says some carriers want to see modifier
-57, even though the CPT code book definition indicates modifier -25 is more appropriate.
Some carriers seem to prefer -57, even when you do a simple procedure here in the office. And they wont pay when you use modifier -25, which is actually the correct way to code the claim, Sutton says.
Note: The use of modifier -25 is currently on the watch list of the federal Office of the Inspector General, and the Health Care Financing Administration (HCFA) now is actively auditing claims that contain this modifier. So utilizing it correctly is more important now than ever, as misuse could trigger an audit, repayment of previously paid claims and fines.
Modifier -57 should only be used when there is major surgery performed within a 90-day global package, according to Medicare guidelines, while modifier -25 is used for procedures with 0- and 10-day global packages.
According to Emily Hill, PA-C, a managing partner with Strategic Healthcare Services, a coding and practice management consulting firm in Bald Head Island, NC, modifier -25 should be used when an E/M service was provided above and beyond any E/M usually included in the procedure.
Hill, a member of the American Medical Associations Relative Value Update Committee and their CPT-5 Project and Correct Coding Policy committees, notes that modifier
-25, used properly, should identify an E/M service so that [...]
