Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) is the most important modifier for pediatricians in Current Procedural Terminology (CPT). But with proper supporting documentation, even if a payer is incorrectly denying services, the billing staff will have a leg to stand on when filing claim reconsiderations. The patient also complains of fatigue, hair loss, feeling cold and lighter menses. The E/M service must be provided on the same day as the other procedure or E/M service. Copyright 2023, AAPC Your email address will not be published. The extra physician work that is documented for all three E/M key components makes this significant. 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. Interested in more urgent care tips, best practices, and industry updates? The diagnostic technique will be tested on more than 1200 patients with suspected lung cancer as part of the clinical trial Credit . Answer the following questions true or false. Modifiers provide additional information to payers to make sure your provider gets paid correctly for services rendered. This can be defined as a problem that requires treatment with a prescription or a problem that would require the patient or family to return for another visit to address it. Manage Settings The decision to boost payment rates was in part the result of a review of new information on the costs of administering COVID-19 treatments to sick patients. Modifier -25 was effective and implemented for hospital use . You can find the latest versions of these browsers at https://browsehappy.com. When it is Inappropriate to Use: Time preparing for the procedure,advising the patient of what is about to happen, and the interpretation or post-work of the proceduredo NOT qualify as time that can be billed as a separate and significant E&M service. Modifier-25 is used for an unrelated evaluation and management (E/M) by the same provider or other qualified health care professional that is a significant, separately identifiable services performed on the same day as another procedure or service. We used that modifier to justify the use of that service during the 90 day global period of Cataract surgery. When billing for an E/M service with modifier 25, it is important to remember that if you dont have a history, exam, and medical decision-making (HEM), you cant bill for an E/M service. Use these five questions to determine whether modifier 25 applies to a specific encounter. Tuesday 25 April 2023, 11:30am. These two PDFs may provide an answer: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c16.pdf; https://www.modahealth.com/pdfs/reimburse/RPM008.pdf. Variations, taking into account individual circumstances, may be appropriate. The professional component is outlined as a physicians service, which may include technician supervision, interpretation of results, and a written report. Modifier 91 describes a repeat clinical diagnostic laboratory test d on the same patienton the same day to obtain subsequent or multiple test results. In this case, the physician would bill for both the E/M service and the flu shot, appending modifier 25 to the E/M service code to indicate that it was a separate service. Is there a different diagnosis for this portion of the visit? TC procedures are institutional and cannot be billed separately by the physician when the patient is: In a covered Part A stay in a skilled nursing facility . Consult individual payers for specific coding instructions. However, an E/M service . Testing services are separately billable and do not require a modifier on the exam. It is appended to the E/M service, Read More Modifier 57 | Decision For Surgery ExplainedContinue, Your email address will not be published. Leverage these game-changing resources to drive your business forward and protect your bottom line. In this months 3 Things to Know About RCM, well provide answers to your E/M modifier 25 questions and share updates to help you recover accurate reimbursement for COVID-19 infusions and vaccine administration. Modifier -25, significant, separately identifiable E/M service by the same individual on the same day of the procedure or other service, is used to report an E/M service that was: Done the same day as a minor procedure, requires a separate OP note and an assessment including more then just the procedure Modifiers 59, 25 and 91: A Guide for Coders - Continuum Save my name, email, and website in this browser for the next time I comment. The problem must be distinct from the other E/M service provided (eg, preventive medicine) or the procedure being completed. This tells the payer that a new or existing problem was addressed at the time of another service/procedure and the patients condition required work above and beyond the other service provided or the usual care associated with the procedure performed. Modifier 25 fact sheet - Novitas Solutions Some insurance companies may require separate co-payments on both services. Nationally, the average payment will go up from $310 to $450 in most healthcare locales, according to the release. hb```f``j``e`Px @16B v=``Rr~PjI}_$Y Note: Modifier 59 should not be appended to an E/M service. Examples of procedures that require modifier 25 include a patient who visits their physician for a routine check-up and receives a flu shot during the same visit. %PDF-1.6
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It would be appropriate to bill both an E/M service and a laceration repair code because your work was above and beyond what is typically associated with a routine preoperative assessment of the laceration. For the following situations, bill the minor surgical procedure code in addition to the appropriate level E/M service: At a follow-up visit for the patients stable hypertension and osteoarthritis, the patient also complains of a troublesome skin lesion that you remove at that same encounter. %%EOF
Modifier 25 is not considered valid when appended to surgical codes, medicine procedures, diagnostic tests and procedures, etc. You may even want to use headers or a phrase such as A significant, separate E/M service was performed to evaluate .. If the providers documentation indicates the encounter included discussions about an unrelated condition or separate existing problem, it supports a separate E/M and applying modifier 25. 1. Per NCCI: "With most XXX procedures, the physician may perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. Copyright 2023 American Academy of Pediatrics. The physician who interprets the X-ray submits a claim with modifier 26 appended (e.g., 71045-26). Hello, Modifiers are two-position alpha or numeric codes (for example, 25, GH, Q6, etc.) When submitting claims solely of an E/M code, ensure you dont include modifier 25. We are looking for thought leaders to contribute content to AAPCs Knowledge Center. Great article, I just wanted to comment that (under Global Period) XXX is exempt from the global period and not considered a minor surgical procedure. In the review of E/M services billed with the -25 modifier, we will first identify within the medical records the documentation specific to the procedure or service performed on that date . To claim only the professional portion of a service, CPT Appendix A (Modifiers) instructs you to append modifier 26 to the appropriate CPT code. This code can help you to get reimbursed for the extra work you do at certain visits. Make sure your providers show their extra cognitive work, as it will serve a critical role when the payer reviews the claim. A medication increase is made and follow-up arranged in 1 month. Modifier 25 is considered valid on Evaluation and Management (E/M) procedure codes only (based on modifier definition). It will sometimes be based on MDM or total time spent on the acute or chronic problem. Modifier 25 is appropriate when an E/M service is provided on the same day as a minor procedure; defined as one with a 0-day or 10-day global period. A. Please note, Internet Explorer is no longer up-to-date and can cause problems in how this website functionsThis site functions best using the latest versions of any of the following browsers: Edge, Firefox, Chrome, Opera, or Safari. The revenue codes and UB-04 codes are the IP of the American Hospital Association. The technical component includes the provision of all equipment, supplies, personnel, and costs related to the performance of the procedure. An indicator of 1 in the Professional Component (PC)/Technical Component (TC) field on the Medicare Physician Fee Schedule Database (MPFSDB) signifies that modifiers 26 and TC are valid for the procedure code. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an XXX procedure is correct coding. Each surgical code, whether minor or major, is divided into three parts: 1) Preoperative assessment, 2) intraoperative and 3) postoperative. Lets break that down a little further. A 15-month-old girl presents with a fever (103F) and mom states the patient has been tugging at her right ear for 2 days. Fees for the technical component are generally reimbursed to the facility or practice that provides or pays for the supplies, equipment, and/or clinical staff (technicians). The fee for the service will be split, with approximately 60 percent of payment allotted for the technical component, and 40 percent for the professional component. Unless the clinician did something else significant and separate from the initial purpose on the same day of the encounter, you cannot use a separate E/M with modifier 25. As a contributor you will produce quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow and expertise. Procedure Coding: When to Use the Modifier 26 - Continuum Reasonable coders and practitioners can and do disagree about when a separate E/M service is warranted on the day of a minor procedure. Before billing for a separate E/M with modifier 25 its imperative to determine whether a provider performed any additional work above and beyond the work involved in the procedure. 1. Often questions are posed regarding whether to bill an E/M visit on the same day as a procedure and/or other services with modifier 25. Source: Primary Care Coding Alert 2021; Volume 23, Number 6. Diagnosis codes for the symptoms would be linked to the E/M code. Modifier 77 is a billing modifier that indicates that a different provider performed a procedure or service that another provider, Read More Modifier 77 | Repeat Procedure by Another Physician/Health Care ProfessionalContinue, Modifier 57 appends for the service when the physician decides on surgery in an evaluation and management setting. Professional claims and facility claims can include up to four modifiers per CPT/HCPCS code depending upon the service provided. I have been searching for weeks and catch come up with a clear and concise answer. The surgical code includes the evaluation services necessary before the performance of the procedure, so no E/M code should be billed. Yes, based on the documentation, an E/M service might be medically necessary with modifier 25. ICD-10-CM CPT, Z00.121 99393 (Preventive Medicine 5-11 years), F90.1 ADHD 99214 25 (Moderate level MDM E/M service). If the fee schedule does not list separate values for a code with modifiers 26 and TC, the modifiers are not appropriate with that code under any circumstances. There is still lots of confusion when it comes to appending modifier 25 to an E/M code and this article definitely sheds some much needed clarity on it!! It should be pointed out to the family that there would be another co-payment if the patient returned for another encounter to address the problem. It's not appropriate to append to the exam when billing testing services. If your answers to these questions are yes, then you should report the appropriate E/M code with modifier -25 attached as well as the preventive medicine service code or minor surgical procedure code. PDF Modifier -25 - Significant, Separately Identifiable E/M Service To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. The clinic will append modifier TC to the appropriate chest X-ray code (e.g., 71045-TC, Radiologic examination, chest; single view-technical component) to account for the cost of supplies and staff. Allergist/Immunologists must document and defend a separately identifiable E&M service when using the 25 Modifier. Discover resources that will help you protect your practice and careernow and in the future. When it is Unnecessary to Use: Some procedures/services are inherently different than the nature of an E&M and thus CCI edits (Correct Coding Initiative)state that the E&M andthe additional service can bebilled without any need for a 25 modifier on the E&M. However, know your payer and its policy with this complicated coding area. All Rights Reserved. A provider may also render two E/M services to the same patient on the same day. Using Modifier 25 can be tricky. Modifier 91 describes a repeat clinical diagnostic laboratory test d on the same patienton the same day to obtain subsequent or multiple test results. Understanding When to Use Modifier -25 | AAFP When deciding whether modifier 25 should be appended, ask yourself the following questions: Note, 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. Bill Type Codes. It creates the opportunity to capture physician work done when separate E/M services are provided at the time of another E/M visit or procedural service. How to Use Modifier 25 Correctly - American Academy of Orthopaedic Surgeons We and our partners use cookies to Store and/or access information on a device. Unfortunately, not all insurers will pay you for the separate E/M service even if you code in compliance with CPT rules. A chest X-ray is performed in a freestanding radiology clinic, and a physician who is not employed by the facility interprets the films. A global service includes both professional and technical components of a single service. Billing a separate E/M while using this modifier (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) correctly will help you collect the most accurate reimbursement for services and avoid payer scrutiny. Be sure a new diagnosis is on the claim form and, if performed, include an assessment. Separate payments may be made for the technical and professional components of a procedure if, for example, a facility provides the technical component of a service/procedure, while an individual physician performs the professional component. Example, Pt John D has carotid at Dr. Feel Good private practice; carotid ultrasound was performed 1/01/2020, physician read and interpreted study images and finalized report 12/01/2020 but global charge was billed to Medicare on 1/03/2020. A new diagnosis, separate from any diagnosis related to the procedure, would also create a strong case for E/M-25. What does modifier -25 mean? It will not only result in cleaner claims and quicker resolution but will keep claims from undue scrutiny. This additional work would be considered part of the preventive service, and the prescription renewal would not be considered significant. CPT is a registered trademark of the American Medical Association. A 44-year-old established patient presents for her annual well-woman exam. When reporting a global service, no modifiers are necessary to receive payment for both components of the service. Some carriers will still bundle payment of theE&M into theultrasound if a 25 modifier is not used. A neck-to-groin exam is performed, including a pelvic exam, and a Pap smear is taken. In the following situation, you should bill the minor surgical procedure code only: The patient complains of a troublesome lesion, you evaluate the lesion and you remove it at that visit. The E/M service must be significant, the documentation must substantiate this, and the physician work must be medically necessary. All necessary components of a preventive medicine E/M visit are provided including hearing and vision screening, appropriate laboratory tests, and immunizations. The patient also requests advice on hormone replacement therapy. Most often, youll see this among diagnostic procedures and services such as radiology, stress testing, cardiac catheterization, etc. Read more on how to bill modifier 25. . Often coders would confuse appending modifier -25 to E/M if patient also requested to have an immunization, if either original appointment was a follow-up or a walk in appt cor a different problem. Be sure to have your staff appeal any denied or bundled claims. A global service includes both professional and technical components of a single service. Some payers, continue to fail to recognize modifier 25 and its appropriate use.
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