Wiki Modifier 25 usage or overusage

[RABBIT2020]

Recently an internal rule commanded the coders to append modifier 24,25 to evaluation and management cpt.
"add modifier 24 or 25 to avoid potential inclusive denial due to possible inclusion of other services on the same dos."

For me an E/M service that stands alone does not require a modifier 25
For me a preventative service together with and E/M will require a modifier 25 on the E/M

With the internal rule the claim looks like this:
99205-25 vs 99205
or
99385-25 vs 99385
99201-25 99201-25

While the use of modifier 25 may not affect payer reimbursement it may or may not be correct coding.
please provided your insight on this whether it is significant to coding practices.
Thanks for all comments.

 

[Orthocoderpgu]

Something is off here. And using modifiers -24 & -25 indicate to the insurance company that two codes have the possibility of bundling, but don't due to the specific circumstances. Example: Patient who comes in FOR a joint injection, 20610, only the 20610 code should be billed. If however DURING THE OFFICE VISIT the physician identifies the need for a joint injection then the office visit and injection would both be billed 99213-25 20610-RT. Using modifiers when they are not needed or supported is going to cause issues and can be seen as a fraudulent move as well.

We have a local insurance company that wants the modifier -25 used when it's not needed. And it's ok to code the way for that insurance only. I suspect that management has come across a situation like that and just want to create a "blanket policy' to avoid the issues with other carriers. Well, if your using the modifiers inappropriately its going to cause even more issues.

 

[thomas7331]

Modifiers 24 and 25 are both coded based on the requirements defined by CPT for those modifiers. If they are appended to every E&M code without review of the documentation to determine whether or not it meets those requirements, then there is of course no way to know whether or not the coding is correct. I don't know why a practice would go to the expense of hiring a coder if they simply want the modifiers on every claim - a data entry clerk could do that.

While you are correct that appending a modifier 25 to stand-alone E&M service would not affect payment, that would not be the case if other services were billed on that same date. And it would certainly not be the case with modifier 24 if the E&M service falls in the global period of a surgery. In addition, appending modifiers to every claim will most certainly make the practice a very easy target for payers looking to recover overpayments - all major payers are very aware that modifier abuse costs them money and they have systems in place to flag providers that bill these modifiers excessively.