Modifier 25 Primer Use It Dont Abuse It

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Modifier 25 Primer: Use It, Don't Abuse It

 

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®). 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. This allows for more efficient use of your time and may save the patient another visit. However, use of this modifier has been associated with frustration because many payers, including Medicaid, do not recognize it. The landscape is now changing, with many major payers facing the pressure of successful class-action lawsuits requiring them to recognize and follow CPT guidelines, including modifier 25.

The use of modifier 25 has specific requirements. 

 

  1. The E/M service must be significant. The problem must warrant physician work that is medically necessary. 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. A minor problem or concern would not warrant the billing of an E/M-25 service.
  2. The E/M service must be separate. The problem must be distinct from the other E/M service provided (eg, preventive medicine) or the procedure being completed. Separate documentation for the E/M-25 problem is helpful in supporting the use of modifier 25 and especially important to support any necessary denial appeal.
  3. The E/M service must be provided on the same day as the other procedure or E/M service. This may be at the same encounter or a separate encounter on the same day.
  4. Modifier 25 should always be attached to the E/M code. If provided with a preventive medicine visit, it should be attached to the established office E/M code (99211–99215).
  5. The separately billed E/M service must meet documentation requirements for the code level selected. It will sometimes be based on time spent counseling and coordinating care for chronic problems.

 

Other issues include the importance of linking each CPT service provided to a distinct International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code. This clearly supports the medical necessity of furnishing the E/M-25 service separate from another procedure or E/M service. However, while a separate ICD-9-CM code may help to support medical necessity for the 2 distinct services, CPT points out that it is not always required. Under the guidelines for the Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions section (90760–90779), it states that different diagnosis is not required to use modifier 25.
 
Some insurance companies may require separate co-payments on both services. Although one of the co-payments may be dropped if the patient appeals, this unfortunate requirement is subject to the family’s plan benefit design and is not controlled by you, the provider. You are contractually obligated to comply with the plan’s requirements. 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. This would require a significant additional investment of time and would be inconvenient.
 
Example 1
 
A 5-year-old boy is seen for his preventive medicine visit. All necessary components of a preventive medicine E/M visit are provided including hearing and vision screening, appropriate laboratory tests, and immunizations. He has diagnosed attention-deficit/hyperactivity disorder (ADHD) and is on a stimulant medication. The patient is evaluated for his ADHD, and multiple parent concerns are discussed. A medication increase is made and follow-up arranged in 1 month. Fifteen minutes of face-to-face physician time is spent in counseling for this problem, addressing parent concerns and behavior management.
Complete documentation of the preventive medicine visit is made on an age-appropriate preventive medicine template. The ADHD is addressed with separate documentation on the back of the template form with careful notation of the 15 minutes devoted to counseling for this diagnosis.

Coding​ ​
CPT ​ICD-9-CM ​
99393 ​V20.2 ​
Preventive medicine​Well-child visit (5–11 y) ​
99213-25 ​314.01 ​
(15 minutes)​ADD with hyperactivity​​
 
Example 2
 
A 15-month-old girl presents with a fever (103°F) and mom states the girl has been tugging at her right ear for 2 days. A detailed history is obtained and a problem-focused examination is completed. When the doctor examines the ears he notices that the middle ear is very inflamed (pus is present) and the child is extremely uncomfortable. The doctor decides to administer ceftriaxone sodium to the child. The final diagnosis is acute suppurative otitis media without rupture of eardrum.
 
Coding​ ​
CPT ​ICD-9CM ​
99213-25 ​382.00 ​
90777 ​382.00
J0696382.00
Some carriers, such as Ohio Medicaid, continue to fail to recognize modifier 25 and its appropriate use. Therefore, to get paid for seeing Medicaid patients with significant concerns, another visit on another day will be required for these patients’ Early Periodic Screening, Diagnosis, and Treatment visits or their medical concerns. It should be pointed out that some Medicaid managed care companies may allow and pay for these services consistent with the CPT guidelines.

The bottom line is to maximize your efficiency seeing patients and maximize their convenience in your medical home by providing medically necessary E/M-25 services at the time of another significant and separate E/M service or procedure. However, know your payer and its policy with this complicated coding area. You don’t want to get caught not receiving payment for the work you do or with a potential Medicaid payback!

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.  

CPT Copyright 2012 American Medical Association. All rights reserved.
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