Separate Out When to Use Modifier 25

Posted on 7 Aug, 2018 |comments_icon 0|By Elizabeth Debeasi
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KNOW THE BASICS

Use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the day of the procedure or other service) to identify when a patient has a separate E/M service along with a procedure or other service on the same day by the same physician. You can submit a separately identifiable E/M service code and modifier only if the documentation meets specific criteria. When the documentation clearly and distinctly proves that a significant and separately identifiable service was done, you may report modifier 25 with the E/M code (not the procedure code) to tell the patient’s insurance they need to pay for both services.

Payers do not always clearly define what constitutes significant and separately identifiable work. In general, however, documentation that supports a separate E/M service must include proof that the service is:

  • Significant and medically necessary. The service must meet the criteria for reporting the E/M level in the first place and the documentation must support that.
  • Separate and distinct from other services. Most procedures include an element of E/M; therefore, the E/M service must be able to stand by itself as a truly significant and separately identifiable service. (Check CPT® guidelines for help in determining whether the service is truly separate and distinct.)
  • Provided on the same day as another procedure or E/M service. This generally means either at the same encounter or a separate encounter on the same day.

BOTTOM LINE

The patient’s symptoms or condition often justify a separate E/M service. Payers all typically recognize and allow you to report an E/M service on the same day of a procedure when the documentation shows that the E/M service is for a condition unrelated to the procedure. Payers generally also allow you to report two E/M visits when the provider addresses more than one problem, and each problem involves separate HEMs as long as each problem requires a medically necessary service. Payers differ, however, in their recognition and reimbursement policies for modifier 25, so check with your individual payers for guidance.

Medicare has specific guidance for when you can report a significant and separate E/M visit. When billing Medicare, you can report a separate E/M visit when:

  • The separately identifiable E/M visit occurs the day before a major surgery and it is not the decision for surgery visit
  • The E/M occurs the day of a procedure with a global period if the physician documents that the E/M is for a significant, separately identifiable service above and beyond the usual pre- and post-operative work for the procedure

Examples

  1. A provider removes a wart at the same time she sees a patient for an upper respiratory infection, an unrelated condition requiring a significant and separately identifiable E/M service. You report the wart removal and you can also report the significant, separately identifiable E/M for the sinus infection with a modifier 25 appended.
  2. A provider sees a patient for her regular follow-up visit for hypertension, and the patient mentions she is having difficulty hearing out of her left ear. The provider then examines and removes a large amount of impacted cerumen from her ear. You may report the cerumen removal and you can also report the separate E/M with modifier 25 appended.
  3. A provider examines a patient for knee pain diagnoses. The patient has osteoarthritis of the knee. The provider discusses options for management and then injects a steroid to provide pain relief. You can report both the injection and you can also report the same-day E/M in this case using the appropriate E/M service level, with a modifier 25 appended.

TIP: Have your provider write or dictate her notes so that documentation for the separate E/M service is clearly separate from documentation for the other services or procedures. This can simply be the physician stating or writing a header such as “A significant and separate E/M service was necessary for …” This separate documentation for the E/M-25 problem is especially helpful for denial appeals as it allows you to easily highlight supporting evidence.

Learn more about modifier 25—and all the CPT® modifiers with TCI’s Modifiers Explained 2018.

Author

Elizabeth Debeasi
Marketing Writer/ Editor

Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of Telehealth services.

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