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Opinion needed on 25 modifier

  1. Smile Opinion needed on 25 modifier
    Clearnace Sale
    Hi All...

    Just looking for some opinions on use of the 25 modifier. We are a private practice and Medicare was here and did some training, but stated that we should only use the 25 modifier if the E&M was performed for a reason unrelated to the other procedure performed (in most of our cases: a Toradol Injection)....

    We scheduled our patient for the E&M because of the narcotics she is on, and to renew her prescription(s)...during the course of the exam, she complained that her pain was higher than usual and requested that we do the injection.

    When we billed we did use the 25 modifier on the E&M, which did get paid. But after reviewing their (MCR's) examples...I am more confused now than before on the appropriate use of this modifier.

    We had also used an E&M with modifier 25 when refilling pump patients, but can see their point that there is no unrelated E&M for these visits (Although our Pump Manufacturer says to use the E&M with a 25 modifier)...

    Any opinions are GREATLY appreciated!!


  2. #2
    25 does not mean unrelated nor does it require the E/M to be unrelated to the procedure.

    Obviously it would save Medicare a lot of money if that was the only time you used the 25, but it would be incorrect.

    Your example of the toradol sounds correct to me. Had the patient been scheduled just to get the injection and only saw the nurse then no you would not have a separately billable E/M.

    All procedures have a little E/M built into them, when you go above and beyond that is when you code out the E/M in addition to the procedure and use the 25. There are several threads about the proper use of 25, I would suggest browsing thru those maybe they will clear up some of the confusion.

    Laura, CPC, CEMC

  3. Thumbs up Modifier 25
    Can we say we see red when Medicare gives directions? Modifier -25 is absolutely correct to use with or without a related diagnosis (for the procedure being performed). It simply makes the statement that in addition to the E&M, you are performing a separately identifiable procedure during the same session.

    Sure, if the patient was coming in just for an injection and this was scheduled from an earlier encounter, then just the procedure would be used. But, as you state, the patient came in for a visit and during that visit stated she had pain, then the decision was made right then and there and not at a previous visit.


    Have a good one


  4. #4
    This is a hot topic in my practice as well, I came across this site here is the link click on third line from the bottom. In the instance of the toradol, I too would have applied the appropiate E/M with a -25 mod with the c/o increased pain, and other elements a evaluation was justified.

  5. #5
    Thanks for the link Ahmed!

  6. Default
    I appreciate the input from the previous replies. Somehow I also had gained the impression that the E/M service had to be unrelated to the procedure. I think I probably got that message from Medicare "literature". I code for general surgeons that routinely see Medicare patients in the hospital to evaluate them for insertion of central venous access devices including the necessary review of systems and then proceed to perform the insertion. I was uncertain if charging for the E/M service with the inclusion of modifier 25 was proper in addition to charging for the insertion. My physicians are extremely diligent and devote considerable amount of time in their evaluation of their patients such as those I described above. I therefore was becoming very frustrated with the idea that I should discontinue charging for the E/M service.

    Thanks immensely,


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