Wiki Modifier 25 usage for Professional Charges within the Emergency Department

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rmyohn

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Having some issues in regards to when to use and not to use Modifier 25 on the professional charges within the Emergency Department. Currently, if the provider does anything over and above a physical exam (i.e, reading of EKG completed by another physician within the department; laceration repairs; POC US; etc.), we have been adding the 25 modifier to the professional charge. We are now being told by our auditing team, that we are doing this inappropriately. We are being told that unless there is some other dx code associated with the ED visit, we cannot add the modifier.....and in some cases, should not even be adding the E/M code for the visit. For example, if a patient comes in for a laceration repair and no testing or lab work is completed, the laceration repair should be the only thing billed with no E/M level. I understand this from a department that has scheduled appointments, but would this still apply to the Emergency Department when the providers have no idea what the patient is coming in for until they get in the room?? I feel like billing the professional charges for Emergency Providers is different than billing professional charges for Family Medicine or other specialty providers. Any insight is greatly appreciated. Thank you
 
The diagnosis alone does not dictate whether or not one appends Modifier 25; the documentation does. Now, if your folks are just "blanket" appending Modifier 25 on everything, that is incorrect. If you are appending it to a service where the documentation supports it, that is fine. The auditing team is misguided if they are telling you a 25 is never allowed and an E/M is never allowed if there is not a different dx and there was a minor procedure. The CMS Manual states different diagnoses are not required. They are doing the physicians a great disservice by doing this.

Resources:
B. CPT Modifier “-25” - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure
"Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim."


"We exclude these global surgical payment services. You may bill them separately and get paid:
● Surgeon’s first evaluation to find the need for major surgeries. Bill this separately using modifier 57 (Decision for Surgery). Only bill this separately for major surgical procedures. Note: Always include the first minor surgical procedures and endoscopy evaluation in the global surgery package. We include minor surgery or endoscopy visits by the same provider on the same day in the global package unless they do a significant, separately identifiable service. Use modifier 25 to separately bill an identifiable Evaluation and Management (E/M) service by the same provider on the same procedure day."

FAQs: Evaluation And Management Services (Part B)

www.novitas-solutions.com www.novitas-solutions.com
"4. How does Novitas review an E/M billed with modifier -25? Modifier -25 is used to report significant and separately identifiable E/M services by the same physician on the same day of the procedure or other service. In the review of E/M services billed with the -25 modifier, we will first identify within the medical records the documentation specific to the procedure or service performed on that date of service. We also consider the additional documentation for the additional service separate from the documentation specific to the initial procedure or service to determine: If there is a significant, separately identifiable E/M service that was rendered and documented, and If the required components of the E/M service are supported as "reasonable and necessary" per Social Security Act, Section 1862(a)(1)(A), and If the level of care is supported by the documentation contained in the medical records."


Not your state, but has clinical examples:
 
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