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Wiki 25 modifier

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nharrison2

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These are denying more often. I was taught that this 25 separated the decision from the procedure. But now I see that the code does not support the decision but it does say "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided" in the description on coding today, the website I use. What would this look like?
 
Essentially, many (including minor) procedures inherently include the E&M decision. CCI edits discuss this in detail. I'm not sure what website you are coding from, (and I advise that you use only regulatory guidance), but they're saying that the decision for the procedure may allow for an E&M.
Unfortunately, most commercial payers automatically bundle, and Medicare is clear that significant and separately identifiable documentation is all that would support the additional E&M, which is difficult to support when the E&M is all about the decision for the procedure.
 
The modifier -25 doesn't really indicate the decision to do the procedure, so much as "I decided to do it today rather than a week from now." Because if they decided to schedule for the procedure a week from now, they'd still have enough to support the E/M visit was done and medically necessary.

In the case where the patient was already scheduled for a procedure, the E/M services to examine them to make sure they're okay to have the procedure that day are bundled into the procedure code.
 
From NCCI: Chapter 1, General Correct Coding Policies

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service.
However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedures do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.
 
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