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Eli's Rehab Report

Reader Question:

Do Therapy Evaluations Require -25?

Published on Mon Oct 01, 2001 Print Friendly and PDF PDF

Question: I was told last fall to use modifier -25 with 97001 through CPT 97004 PT and OT evaluations if they were done on the same day a patient received therapy, and I have used it successfully. However, I now have one local payer denying these claims, saying that -25 is an invalid modifier for the CPT code. I've only seen -25 used with E/M codes, but it was my understanding that 97001 through 97004 were considered E/M. Is that correct?

Oregon Subscriber
 
    
Answer: Therapy evaluations are not technically considered E/M codes, but this has not stopped some carriers from erroneously requiring the 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) with claims for these services. In October 2000, Medicare added a CCI edit requiring that -25 be appended to most codes in the 90000 series, but that edit was rescinded in January of this year. However, despite very specific instructions from HCFA (now CMS), many carriers did not remove the edit and still require practices to use modifier -25, although it is inappropriate.
    
What has happened to you is fairly common: Several of your carriers are still requiring modifier -25 to process your therapy claims, while another carrier is properly following CMS' instructions and no longer requires modifier -25 to bill for therapy evaluations.
    
You should write to the carriers that still require modifier -25, and include a copy of Medicare's January memo rescinding the edits, and inform them that modifier -25 should no longer be required to process claims for therapy evaluations. In the meantime, you will have to file your claims based on the carriers' current requirements. Although this can take a lot of time, it is probably the only way you can collect reimbursement without denials and refilings for these claims.
     
Claims must be refiled within a year of submission of the original claim. Don't forget to refile claims made between Oct. 1, 2000, and Jan. 1, 2001, as soon as possible.

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