How to avoid modifier 25 denials

Q: Please explain modifier 25 and it’s proper use. Can you present some scenarios for how to use the modifier when providing various services during one encounter, including visits, vaccines and other services?

A: Modifier 25 is defined as a “significant, separately identifiable Evaluation and Management Service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.” As the definition indicates, modifier 25 should always be appended to an Evaluation and Management (E/M) code. 

I’ll address three scenarios using modifier 25.

They are:

• a physical, a sick visit and vaccines done on the same day,

• a sick visit and vaccine done the same day, and

• a sick visit and a precure, such as a nebulizer, ear lavage, or rapid strep screen, done on the same day.

Scenario 1

First, a physical/preventive visit (99381-99387, 99391-99397), a sick visit E/M (99211-99215) and vaccines (vaccine and administration code) performed on the same date of service should be coded with the 25 modifier appended to the sick visit E/M code.

For example:

• 99385

• 99212-25

• 90741 (or G0008 for Medicare patients)

• 90688

Keep in mind that, when billing a preventive visit code with an E/M, the E/M code should be an established-patient code. 

This is because most insurance payers won’t pay for two new-patient codes on the same date.

Secondly, the documentation for these combination visits isn’t going to support a new-patient code. The documentation elements (for example, review of systems, past family and social history, exam) are credited for the preventive code and can’t be additionally counted for the E/M.

Next: Scenario 2 and 3

Scenario 2 and 3

Scenarios two and three include a sick visit E/M (i.e., 99201-99215) and vaccine or lab performed on the same date. 

For most payers, modifier 25 is not required on the E/M code when billed in conjunction with a lab service(s), immunization(s), or x-ray(s). I will caution again that you need to check with each payer to ensure this is the practice they want followed. 

For the last scenario – a sick visit and a procedure (i.e., a nebulizer or ear lavage) performed on the same date, modifier 25 would need to be appended to the E/M code, such as:

• 99213­-25

• 69210 (Removal impact cerumen requiring instrumentation, unilateral)

The use of modifier 25 does vary by payer, so be sure you check your remittance advice to ensure that you don’t have to deal with any unexpected claim denials.

The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your coding questions to medec@advanstar.com.