Thursday, May 20, 2010

Level I Modifiers 25

 Level I Modifiers 25

Description : Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

Required for Claims Hospital Outpatient Prospective Payment System (OPPS)

Type of Bill : 13X

Coding Guidelines Modifier -25 can only be applied to the following HCPCS/CPT codes:  92002-92014, 99201-99499 and G0101 and G0175


General Guidelines

A. Modifier –25 is billed with an evaluation and management (E/M) CPT code to indicate that the patient’s condition required a significant, separately identifiable E/M service on the same day a procedure was performed. This documentation should support that the E/M service was beyond the procedure that was provided (or beyond the usual pre-operative and post-operative care associated with the procedure performed).

B. Modifier –25 should always be appended to the Emergency Department (E/M) code (99281-99285) when provided on the same date as a diagnostic or therapeutic medical/surgical procedure(s). For hospitals paid under the outpatient prospective payment system (OPPS), these procedures are identified with a status indicator of “S” or “T”.

NOTE: It is appropriate to hard code the –25 modifier into the charge master for EMERGENCY DEPARTMENT E/M services.

C. When a modifier –25 is appropriate, it is NOT necessary that the diagnosis code for the E/M service be different that the diagnosis code for which the diagnostic and/or therapeutic medical/surgical procedure(s) was (were) performed.

D. It is appropriate to append modifier –25 to the qualifying E/M service code regardless of whether or not the E/M and procedure were provided by the same physician/practitioner.

E. Payment for diagnostic (with the exception of pathology and laboratory) and/or therapeutic procedure(s) (code ranges include: 10040-69990, 70010-79999 and 90281-99140) includes taking the patient’s blood pressure, temperature, asking the patient how he/she feels and getting the consent form signed. Since payment for these types of services is already included in the payment for the procedure, it is not appropriate to bill for an evaluation and management (E/M) service separately.

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