Monday, November 14, 2011

Examples of Proper and improper Use of the 25 Modifier and key points

Examples of Proper Use of the 25 Modifier


Example 1: A patient has a nosebleed. The physician performs packing of the nose in the office, which stops the bleeding. At the same visit, the physician then evaluates the patient for moderate hypertension that was not well controlled and adjusts the antihypertensive medications.

The 25 modifier may be reported with the appropriate level of E/M code in addition to the minor procedure. The hypertension E/M was medically necessary, significant and a separately identifiable service performed on the same day as control of the nosebleed. The hypertension was exacerbating the nosebleed and was actually related to the nosebleed, but management of the hypertension was a separate service from actually packing the nose.

Example 2: A patient presents to the physician with symptoms of urinary retention. The physician performs a thorough E/M service and decides to perform a cystourethroscopy. Cystourethroscopy is performed the same day as the E/M code.

The 25 modifier may be reported with the appropriate level of E/M code in addition to the cystourethroscopy. The physician had to evaluate the patient based on the symptoms and decides on the procedure to be performed. The procedure was then performed on the same day as the E/M.



Examples of Improper Use of the 25 Modifier

Example 1: A patient has a small skin cancer of the forearm removed in the physician’s office. This is a routine procedure and no other conditions are treated. The office visit is considered part of the surgery service and, therefore, not separately reimbursable. The use of the 25 modifier is inappropriate. Only the surgical procedure should be reported.

Example 2: A patient visits the physician on Monday with symptoms of GI bleeding. The physician evaluates the patient and bills an E/M service. The physician tells the patient to return on Wednesday for a sigmoidoscopy.
On Wednesday, a sigmoidoscopy is performed in a routine manner.
An E/M service (no modifier applied) may be billed for the service provided on Monday. However, a separate E/M service should not be reported for Wednesday when the patient returned for the sigmoidoscopy



Key Points

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician/practitioner in the patient’s medical record to support claims for payment of the E/M service and the procedure with the global fee period. This documentation must be made available if requested by the carrier.

The 25 modifier should be used to designate a significant, separately identifiable E/M service provided by the same physician/practitioner on the same patient on the same day as another procedure or service with a same-day or 10-day global period.

The 25 modifier identifies a significant, separately identifiable E/M service. It should be used when the E/M service is above and beyond the usual pre- and  postoperative work of a procedure with a same-day or 10-day global fee period performed on the same day as the E/M service.

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier 25 should be added to the E/M code on the claim. 

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