Modifer 25: Are you using it correctly?

Question: Can you review the correct use of modifier 25?

Answer: The Centers for Medicare & Medicaid Services (CMS) continues to identify the potential overuse and misuse of Current Procedural Terminology (CPT®) code modifier 25. This issue has been raised multiple times over the years, so it is worth revisiting again.

To understand why modifier 25 is under this type of scrutiny, physicians need to understand how its use is defined. Simply put, modifier 25 is appended to an E/M code when a procedure and a separate and significant E/M service is performed by the same physician during the same session or on the same date. For example, an established patient comes to your office with a suspicious lesion and, based on your assessment, you decide to excise it. You wonder if you can report an E/M code with modifier 25 appended, as well as the minor procedure code for excising the lesion. The definition of what is “separate and significant” is at the heart of whether both an E/M with modifier 25 and a procedure code may be reported together.

Definition of Modifier 25

Medicare and CPT require that modifier 25 be used only on claims for E/M services and only when the E/M service is provided by the same physician on the same day as a global procedure or service. In addition, payment is made only if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual preoperative and postoperative work required on the day of the procedure. The physician must appropriately and sufficiently document both the medically necessary E/M service and the procedure in the patient’s medical record to support the claim for these services, even though the documentation is not required to submit with the claim.

Significant and Separately Identifiable

What exactly does significant and separately identifiable mean? How do you know when you have performed this service and therefore need to document a significant and separately identifiable E/M service? It is important to note that the relative value unit (RVU) for each minor procedure includes pre-service work, intra-service time, as well as post-procedure time.

Reporting an E/M code and a procedure code when your evaluation is limited to assessing the specific problem (for example, an abscess) is essentially double billing for the pre-service evaluation. Your E/M must significantly exceed the pre-service evaluation already paid as part of the procedure for it to qualify as significant and separately identifiable. If it does not, only the procedure should be billed.

A different diagnosis code is not needed, and in some cases the diagnosis code for the E/M code and the procedure code will be the same. What must be documented is the history, exam, and decision-making process that includes attention to more than the patient’s targeted chief complaint that is the reason for the minor procedure.

Example of an encounter resulting in the reporting of both a procedure code and E/M code with modifier 25, with one diagnosis:

A patient arrives at your office complaining of bright red blood from the rectum. You conduct a detailed history and physical exam including abdominal, rectal, and genitourinary examination. You then perform a diagnostic anoscopy. Your medical decision making is aided by the anoscopy findings but is based on the history and physical exam. Report the anoscopy and an appropriate E/M code with modifier 25. Only one diagnosis should be reported.

Example of an encounter resulting in only reporting a procedure code:

A woman arrives at your office for a repeat injection of steroid at the base of her right thumb to relieve arthritis pain and swelling. She mentions that she has recently had the same pain on her left hand. After a focused exam of her left hand, you decide to perform a second injection. Report the injection code with modifier 59 and modifiers to indicate left thumb and right thumb as appropriate. No separate E/M code should be reported.

Renee Dowling is a compliance auditor for Sansum Clinic, LLC, in Santa Barbara, California.