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When and How to Use Modifier -25
By Amy Wright, CPC-H, CCP-H, CPC, CCP, CMBS

Modifiers are two-character alpha-numerics reported with a CPT code when appropriate. They provide Medicare and commercial payers with additional—and essential—information needed to process a claim. Modifiers provide the means by which the physician can flag a service that has been altered by some special circumstances without changing the basic CPT code description.

Modifier -25 is important because it allows physicians to obtain reimbursement for services rendered that would otherwise be denied if the modifier was not attached. It alerts payers that another significant, separately identifiable evaluation and management (E/M) service was performed by the same physician on the same day.

Global period refers to a set number of follow-up days included with the procedure performed. They typically are zero, 10, or 90 days after the procedure. This comes into play when an E/M-level visit is completed on the same date of service as a procedure.

Examples of a zero global period with an E/M service provided the day of include bronchoscopy, esophagogastroduodenoscopy, and impacted cerumen in one or both ears.

Examples of a 10-day global period are minor surgical procedures that include complications related to the procedure and cannot be billed separately for 10 days after the procedure, such as the excision of a benign lesion on the trunk, arms, or legs; pressure equalizer tubes inserted under local or topical anesthesia; and debridement.

Examples of a 90-day global period are major surgical procedures that include complications related to the procedure and cannot be billed separately for one day prior to the procedure and 90 days after the procedure such as cataract removal, femoral-popliteal bypass, and mitral valve replacement.

When to Use Modifier -25
A physician performs an E/M service on the same day that a procedure is performed, and the E/M service is for a condition unrelated to the procedure. By adding modifier -25 to the appropriate E/M code, the E/M service may be billed. Documentation should be clear and distinct and show a significant, separately identifiable service was performed. All E/M services must have the required key elements documented. ICD-9 codes should identify the service.

Examples of misuses of modifier -25 include the following:

• reporting an E/M service that resulted in the decision to perform major surgery (-57);

• using it on an E/M service that was performed on a different day than a procedure;

• applying surgical codes (10021 to 69990); and

• billing an E/M service with modifier -25 when a patient’s trip to the office was strictly for a scheduled minor procedure (No separately identifiable E/M service was performed.).

Payers such as Medicare, Champus, Blue Cross, and UnitedHealthcare recognize modifier -25 and will reimburse for E/M services with this modifier attached to the E/M code.

Officials at the Centers for Medicare & Medicaid Services (CMS) maintain that related services may be billed as long as they are significant and separately identifiable, confirming a 10-year-old policy to that effect. Officials at the Office of the Inspector General (OIG) confirmed the CMS' view. The CMS wrote that "a documented, separately identifiable, related service is to be paid for. We would define related as being caused or prompted by the same symptoms or conditions." Nevertheless, it is smart to assume the carrier will ask for documentation that the two services were separate and each was medically necessary.

Medicare will allow separate payment for two office visits provided by the same physician on the same day when each visit is rendered for an unrelated problem. Both visits must be medically necessary, and modifier -25 must be appended to the second visit. Third-party payers vary in their recognition and reimbursement of E/M visits billed with this modifier.

The OIG Work Plans have more than once identified the use of modifier -25 as an area of focus for program review. When an individual or group has been identified, a review of claims and supporting documentation may occur for subsequent charges with modifier -25 attached.

A word of caution: Modifier -25 should not be routinely appended to all E/M services unless all requirements for use have been met. One reason the OIG is looking into modifier -25 is because its initial investigation shows that many physicians do not document separate and identifiable E/M services.

Examples of Appropriate Use
A patient returns to the orthopedic clinic for a scheduled Synvisc injection. The patient also complains of a sore wrist that began two days ago. E/M code: 99213-25. Diagnosis: sprained wrist. Also bill for Synvisc injection. Separate, unrelated E/M service.

Ear, nose, and throat clinic sees a patient for consultation for shortness of breath, hoarseness, and difficulty swallowing. During the consult, a flex laryngoscopy is performed and a laryngeal mass is found. E/M code: 99243-25. CPT code: flex laryngoscopy. The physician can bill for laryngoscopy even though it is related to the E/M visit because the procedure was not anticipated.

An established patient is seen in the orthopedic clinic for a knee aspiration. The patient comes to the clinic on a regular basis for knee aspiration. E/M code: None. CPT code: 20610, aspiration of knee joint.

The physician examines a new patient for upper respiratory infection (URI). During the examination, the patient tells the physician that the hearing in his left ear is not clear. Upon examination, the physician notes a large amount of impacted cerumen, which he removes. E/M code: 90203-25. Diagnosis: URI. CPT code: 69210. Diagnosis: impacted cerumen.

— Amy Wright, CPC-H, CCP-H, CPC, CCP, CMBS, acts as a coding and compliance consultant with Kraft Healthcare Consulting, LLC, an affiliate of Kraft CPAs PLLC.