Wiki Modifier 25

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jferko

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03.2023 - Wondering if others can comment . . . there was a lengthy discussion on the application of Modifier 25 on E/M codes WITH Xrays back in 2015. 8 years late - curious if others are seeing / aware of this being standard practice expected from the major payers? Our coding company is stating that most payers DENY xrays without the 25 Modifier on E/M. I am hoping to find or have access to something 'credible' to support this statement. We are an Orthopaedic clinic that regularly OPI xray with visits.

I am recently re-certified (within past 2 years) and NO MENTION of this application of Mod 25 in AAPC training or testing.

Thank you for any references to support this increased use of Mod 25.

Julie Ferkovich
CPC
 
If we're talking in-office/pro-fee physician, I have never seen this in 20+ years with many of those in ortho coding, AR, and Rev cycle management. I have never personally appended a 25 to an E/M with just an XR as the only other line item on the same date. I cannot recall a single instance where one was denied due to missing a 25. I would have been losing my mind if that happened. It makes no sense. However, there could be a payer out there that *might* require it. You would have to check your payer. But again, it makes no sense. Blanket application to every single one for all payers is a recipe for disaster. Might be a facility (OP) versus office/physician question? If talking facility there could be a reason for it but then status indicators come into play.

Not sure how accurate these are, it's discussion, but found:

I would question your coding company. I would also ask for hard data to support their broad statement of, "most payers DENY xrays without the 25 Modifier on E/M." That's not true. What payers? What credible and reputable source documents this? Can they show you YOUR denials and evidence for it? It's easy to run data analytics to see results when the only two codes billed were E/M & XR. I would also say if a 25 is being appended inappropriately on so many visits you are probably going to have auditors knocking.

If you search the fee schedule for XR codes, they are xxx procedures. "Global – XXX appears in this example, which means the global surgery concept isn’t applicable to this code" Which means a 25 is not applicable to the E/M same day. There is no global, there is no pre/post-op work.

Credible links:
"A/B MACs (B) pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure"

Modifier 25 fact sheet

www.novitas-solutions.com www.novitas-solutions.com
https://www.radiologytoday.net/archive/rt_110308p8.shtml (very old link may not be 100%)
 
I agree with Amy.

Also, I wanted to point out that this scenario is outside of the scope for the CPC course and exam, since you mentioned there was no mention of this application of modifier 25 in your recent training.

The CPC covers the foundations of how to navigate the codes (CPT, ICD-10-CM, and HCPC) - it teaches you how to use the coding guidelines, coding conventions, indexes, and appendices to arrive at correct coding. It isn't meant to teach you how every payer is going to want something billed or how they're going to reimburse a service.

The CPB would touch a little more upon those billing nuances, but even then it's not possible for one course to include every possibility that every payer across the country might throw at you.

Amy gave you some great links. You might also look to find any continuing education on use of Modifier 25, or even some ortho specific webinars.

Specialty medical societies can also be a good source of education for coding tips and references. (I'm not an ortho coder, but I refer to my oncology specialty society websites regularly - no matter how much experience a coder has, there's always more to learn!)

It looks like the American Academy of Orthopedic Surgeons has some coding tools on its website - I don't know these tools cover your particular Modifier 25 question, but you might find some useful information for other ortho coding questions on it: https://www.aaos.org/quality/coding-and-reimbursement/coding-community/

Good luck!
 
sls314 said:
I agree with Amy.

Also, I wanted to point out that this scenario is outside of the scope for the CPC course and exam, since you mentioned there was no mention of this application of modifier 25 in your recent training.

The CPC covers the foundations of how to navigate the codes (CPT, ICD-10-CM, and HCPC) - it teaches you how to use the coding guidelines, coding conventions, indexes, and appendices to arrive at correct coding. It isn't meant to teach you how every payer is going to want something billed or how they're going to reimburse a service.

The CPB would touch a little more upon those billing nuances, but even then it's not possible for one course to include every possibility that every payer across the country might throw at you.

Amy gave you some great links. You might also look to find any continuing education on use of Modifier 25, or even some ortho specific webinars.

Specialty medical societies can also be a good source of education for coding tips and references. (I'm not an ortho coder, but I refer to my oncology specialty society websites regularly - no matter how much experience a coder has, there's always more to learn!)

It looks like the American Academy of Orthopedic Surgeons has some coding tools on its website - I don't know these tools cover your particular Modifier 25 question, but you might find some useful information for other ortho coding questions on it: https://www.aaos.org/quality/coding-and-reimbursement/coding-community/

Good luck!
Click to expand...
There is a lot of ortho specific guidance on AAOS and they do have articles and info on modifier 25 (& other mod) usage. KZA also has a lot for ortho https://karenzupko.com/resources/orthopaedics/
 
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