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Modifier 25

MODIFIER 25: HOW TO USE IT APPROPRIATELY

CPT codes are used to report medical procedures and services for processing claims. However, medical coders know that, sometimes, a CPT code might not be enough to report a procedure or service. CPT modifiers ought to be applied with the codes to supply extra data regarding where, and why a procedure was performed. Of the numerous modifiers which will be applied to claims, modifier 25 usually causes confusion.

Modifier 25 is defined as a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”

Reporting associate degree E/M code and a procedure code once your analysis is proscribed to assessing the precise downside (for example, associate degree abscess) is basically double request for the pre-service analysis. Your E/M should considerably exceed the pre-service analysis already paid as a part of the procedure for it to qualify as vital and on an individual basis classifiable. If it doesn’t, solely the procedure ought to be beaked. a special identification code isn’t required, and in most cases the identification code for the E/M code and therefore the procedure code are constant. What must be documented is the history, exam, and decision-making process that includes attention to more than the patient’s targeted chief complaint that is the reason for the minor procedure.

According To Medicare:

  • Modifier 25 is used to facilitate billing of E/M services on the day of a procedure for which separate payment may be made.
  • It is used to report a significant, separately identifiable E/M service by the same physician on the day of a procedure.
  • The physician may need to indicate that on the day a procedure was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and operativecare related to the procedure that was performed.
  • Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service.
  • Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented in the patient’s medical record to support the claim for these services.
  • This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M services

When Not to Use the Modifier 25

  • Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery.
  • Do not append modifier 25 if there is only an E/M service performed during the office visit (no procedure done).
  • Do not use a modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed.
  • Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have “inherent” E/M service included.
  • Patient came in for a scheduled procedure only

Understanding the correct use of modifier 25 and the required documentation is critical to avoiding problems and adjudicating inappropriate claim denials or underpayments. The key requirement of a “significant and separately identifiable” E/M service is that the work for the E/M service is substantially more and different than the typical preoperative and postoperative E/M work included in the minor procedure.

To know more about Modifier 25 and its appropriate uses, please join our upcoming live webinar on May 8:

Modifier 25: Ensure Correct Coding and Payment to Minimize Compliance Risk

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CPT codes are used to report medical procedures and services for processing claims. However, medical coders know that, sometimes, a CPT code might not be enough to report a procedure or service. CPT modifiers ought to be applied with the codes to supply extra data regarding ...
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