Modifier 25 is an important Evaluation and Management service medical professionals need to understand. It is used for same-day procedures when services beyond usual pre and post-operation are necessary. Continue reading below for a breakdown and examples of modifier 25!
By: Sheila Haynes, CPC
Coding and Compliance Manager
Pay close attention to billing E/M (office visits) and minor procedures at the same encounter. The OIG and Federal auditors have added Modifier 25 to their Work Plan “Dermatologist Claims for Evaluation and Management (E/M) Services on the Same Day as a Minor Surgical Procedure”. Even though the title calls out the Dermatology specialty, the overall concern about this issue is much broader. All practices and specialties reporting E/M services separately for minor procedures and/or preventive services at the same encounter should ensure they understand the guidelines and are using this appropriately.
Understanding Modifier 25
- Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.
- It is used to report an E/M on the same day as a minor procedure when the separate/significant service provided is above and beyond the usual pre and/or post operative care associated with the procedure
- Modifier 25 can also be used to report an E/M on the same day as other services such as Preventive, Physicals or an AWV encounter when a patient has a “sick/injury” concern that is separately addressed at the same visit.
- In either circumstance, the documentation must support the separate service was above and beyond the usual pre and/or post operative care or preventive service requirements.
Defining a Minor Procedure
- Procedures with a zero or 10-day post-op period
- Generally E/M services provided on the same day as a minor procedure are included as part of the service.
- The standard time involved in pre-service, intra-service and post-service care has been included in the calculation of the total wRVU’s established for minor procedures.
Understanding Preventive Services (Physicals/AWV)
- Preventive services are usually Physicals and AWV type encounters.
- These are encounters where there is no patient “complaint” of a current injury, illness or condition.
- If a patient has a chronic condition that is evaluated as part of their preventive encounter, this does not necessarily support a separate E/M service. It is expected that the clinician will address chronic conditions during a preventive encounter. If the encounter is stable with no concerns or adjustments to the current care regimen, this does NOT qualify as a separately identifiable E/M service.
Modifier 25 Scenarios
Minor Procedure With a Separate E/M Service: When a patient appointment is scheduled for a minor procedure, then a separate E/M isn’t usually warranted. The exception would be if something else outside of the procedure comes up during the encounter and is addressed.
Example 1:
- The visit is schedule for IUD insertion, which is done, but the patient brings up another issue like breast lump. The clinician does a separate history, pertinent exam and assessment/plan for that separate complaint during the same encounter.
- This scenario would warrant the IUD insertion procedure code AND a separate E/M for the additional issue addressed and documented.
Example 2:
- The visit is scheduled for biopsy for a suspicious lesion of the cheek, which is done. At the same encounter the patient complains of a new lesion on their back. The clinician documents a separate history of the new complaint, pertinent exam and the assessment and plan for this separate issue.
- This scenario would warrant the Biopsy procedure code AND a separate E/M for the additional issues addressed and documented.
E/M Service that Determines a Same Day Procedure: When the patient appointment is for a complaint (illness/injury) and based on a full history, pertinent exam, and assessment the plan is to conduct a minor procedure, that is done at the same encounter, then a separate E/M service is appropriate. In other words, it was not known by the clinician that the minor procedure was warranted or would be the course of action prior to the full evaluation of the patient’s condition.
Example 1:
- The patient appointment was for contraception management and counseling. After the clinician discusses all of the available contraception options, risks and benefits, the patient decides they want an IUD. The provider has the time to complete the IUD insertion at that same encounter.
- This would warrant billing for both the E/M and the IUD insertion procedure because the IUD insertion wasn’t pre-determined prior the visit.
- Documentation must clearly indicate why the patient presented, all of the options discussed with the patient and that based on that discussion the patient chose to go with the IUD. The IUD insertion procedure would also be fully documented.
Example 2:
- The patient appointment is for knee pain. During the encounter the provider documents the history, pertinent exam and the assessment and plan for the knee pain. Provider documents the treatment options reviewed with the patient (e.g. OTC, Rx or Injection therapy). The patient decides they would like the injection therapy and the provider has time to complete the injection procedure during the same encounter.
- Documentation must clearly indicate why the patient presented, the options provided and based on that, the decision for the same day procedure. The Procedure/Injection must also be fully documented.
Preventive Service With a Separate E/M Service: When the encounter is scheduled for a physical/preventive/AWV service and a significantly separate complaint OR an existing condition that is worsening or progressing is also addressed and evaluated during that encounter, then a separate E/M service would be warranted.
Example 1:
- The appointment is scheduled for a physical, which is performed and documented. During the encounter, the patient complains of ankle pain. The provider documents the history of the complaint, pertinent exam and assessment/plan for the ankle pain.
- In this case it’s appropriate to code for both the physical and a separate E/M for the complaint.
Example 2:
- The appointment is scheduled for an AWV, which is performed and documented. During the encounter the clinician addresses the patient’s Diabetes. The patient reveals that their glucose readings are not within range. The provider reviews/discusses the patient’s glucose readings and determines their medications should be adjusted. The provider documents the worsening condition as well as the assessment and course of action.
- In this case it’s appropriate to code for both the AWV and a separate E/M for evaluating and treating the diabetes.
Determining the E/M Level: When a visit supports that a separate E/M service is supported at the same encounter as either a procedure or preventive service:
- Documentation must clearly delineate the two services
- The E/M level chosen must be based only on the documentation of the separate complaint. Don’t “double dip” from either the procedure elements or physical elements when determining the level of service for the separate E/M code.
- If you choose to code the E/M level based on “total time”, do not include the procedure time in the E/M time calculation. The documentation must clearly indicate that the total time documented to support the E/M level chosen, is “only” for the E/M service.