Podiatry Coding & Billing Alert

Modifier 25 is one of the most misunderstood modifiers. In many cases, it is misused, missing or just plainly misunderstood. To really understand modifier 25, first you have to understand what an E/M code is. For the uninitiated, E/M stands for 'Evaluation and Management;" what was traditionally called an "office visit" or "problem visit." E/M service codes are those codes in the range from 99201-99499. These are the only codes that get modifier 25.

"Modifier 25 cannot be looked at in a vacuum; you must understand how it relates to having supporting chart notes, and correct usage with E/M codes," adds Hoda Henein, CHBME, CPL, president and CEO of Active Processing, Inc. in College Point, NY, where she has more than 20 podiatrists on her client roster "Legal, ethical, and moral are all important words in business, and in medicine, but words that are more important are 'policy restriction,'" says Henein. "Many doctors unknowingly misuse modifier 25. It seems to be the general consensus that if an E/M code gets denied, just add modifier 25 -- right? Wrong! You must pay attention to the words 'significant' and 'separately identifiable.'"

For example, in coding scenario #2, "by adding modifier 25 to 99213 you are telling Medicare that the services were unrelated and you are justified in getting paid for both 99213 and 11040," explains Henein. "I say Medicare because a lot of commercial carriers will not pay for each procedure, even with modifier 25 added appropriately. Instead, they will bundle the codes together and pay only one code, regardless of whether you have a modifier 25 present or not.' This is one of the biggest points of contention in medical billing.

Commercial insurance companies seem to want to pay based on the patient encounter, not the CPT codes billed. Adding modifier 25 to your E/M code at least gives you grounds to appeal."

Remember: In order to appeal, you need good notes. Your notes should clearly indicate that modifier  25 was justified and was in fact, a significant and separate service.