Wiki Modifier 25 and 2021 E/M Guidelines

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It seems easier to add the modifier 25/bill a visit together with a minor procedure now that there are no specific requirements for history and exam. For example, if a patient had fungal toenails debrided and also had medication prescribed for the fungal toenails. In the past, we couldn't bill a visit and modifier 25 since there was no separate exam and history. Now if it is only based on medical decision making, why not?

Thank you for your help.
 
Hi - The office and outpatient E/M codes still include a medically appropriate history and exam, and procedures still include the related pre/post-op services (depending on what the global period includes). So proceeding with caution when deciding whether to use mod 25 seems like a good idea to make sure the documentation supports a separate E/M code (and if so which one) once the services paid under another code are excluded.
 
Looking for guidance for documentation to support using 25 modifier,especially with injections (new and est patients). With new documentation guidelines, if no other problems or issues are addressed, I am having difficulty supporting the 25.
 
Looking for guidance for documentation to support using 25 modifier,especially with injections (new and est patients). With new documentation guidelines, if no other problems or issues are addressed, I am having difficulty supporting the 25.
As Deborah stated above, the provider still needs to document a history and exam if medically necessary. If no other problems or issues are addressed and the issue has not changed, then a separately billed visit along with the procedure is not supported, regardless of which guidelines you refer to. Keep in mind that part of the description for "significant and separately identifiable" is "beyond the usual preoperative and postoperative care associated with the procedure that was performed". So that being said, it's not only when the provider is addressing a different issue that an E/M can be billed. This is why, if the patient is brand new or if this is a new issue, an E/M with modifier 25 is often warranted because the provider is doing an evaluation of the patient's history, examining the issue, and determining what treatment is necessary.

Hope that helps!
 
Did you notice that the May 2021 "Healthcare Monthly" magazine has the 25 modifier on the procedure performed in the office and not the E/M office visit? The rationale supported that as well. I thought the 25 modifier was only used for E/M procedures. As to an answer to the above, if you are having difficulty supporting the 25 modifier, an auditor would too. Make sure your MD's documentation clearly indicates a separate E/M that is distinct from the injection.
 
As Deborah stated above, the provider still needs to document a history and exam if medically necessary. If no other problems or issues are addressed and the issue has not changed, then a separately billed visit along with the procedure is not supported, regardless of which guidelines you refer to. Keep in mind that part of the description for "significant and separately identifiable" is "beyond the usual preoperative and postoperative care associated with the procedure that was performed". So that being said, it's not only when the provider is addressing a different issue that an E/M can be billed. This is why, if the patient is brand new or if this is a new issue, an E/M with modifier 25 is often warranted because the provider is doing an evaluation of the patient's history, examining the issue, and determining what treatment is necessary.

Hope that helps!
Hi Kimberly,
You mentioned "if the patient is NEW or if this is a NEW issue, an E/M with modifier 25 is often warranted..."

What about a NEW patient with a straightforward issue such as wart (cryo), impacted cerumen removal, skin tag removal, incision & drainage it would not be permissible to report an E&M service as the clinician is paid for the initial evaluation of the site which then lead to the decision to perform the minor procedure (destruction, removal, I&D), it would only be permissible to report the procedure?

NCCI states
"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 global surgical package for the minor surgical procedure, and shall not be reported separately as an E&M service.....
"The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure."

TIA
 
Last edited:
Hi Kimberly,
You mentioned "if the patient is NEW or if this is a NEW issue, an E/M with modifier 25 is often warranted..."

What about a NEW patient with a straightforward issue such as wart (cryo), impacted cerumen removal, skin tag removal, incision & drainage it would not be permissible to report an E&M service as the clinician is paid for the initial evaluation of the site which then lead to the decision to perform the minor procedure (destruction, removal, I&D), it would only be permissible to report the procedure?

NCCI states
"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 global surgical package for the minor surgical procedure, and shall not be reported separately as an E&M service.....
"The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure."

TIA
That's correct - - that's why I said it is "often" warranted, but not always :)
 
Do you need to add modifier 25 when billing 92250 in Primary Care?
Meaning 92250-25? No, the modifier is not appropriate for use with that code. If you are questioning whether a 25 modifier is needed on an E/M service billed with 92250 on the same day, there is no CCI edit that would bundle the two services. There may be payer specific edits that require a modifier when appropriate.
 
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