If you work in an SIU, chances are you’ve encountered cases dealing with Evaluation and Management services (E/M). In some E/M reviews, you may find yourself mystified by claims billed with Modifier 25. Though this modifier is intended to help create a clear delineation of distinct services, it isn’t always cut and dry. In our latest article, our rockstar team shares some important information to help you navigate the complexities of this modifier.

How to Arrive at 25: The Enduring Complexity of 25 Modifier

Some of the most commonly billed codes in the U.S. healthcare system represent evaluation and management (E/M) services. E/M procedure codes report the assessment, treatment, and maintenance of a patient’s condition; however, situations often arise when clinicians treat separate concerns and perform additional services at the same time, warranting appropriate distinction when billing for reimbursement.

Simple, right?

While modifier 25 is intended to add clarity when reporting the services rendered, nuances surrounding the appropriate usage of the modifier continue to puzzle providers and coders alike. From definition to documentation and application, the persistent ambiguity around this modifier often leads to a whirlwind of questions and concerns. Let’s try and unpack them.

Background

The American Medical Association (AMA) defines modifier 25 as, “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.”

The application of modifier 25 is appropriate for two E/M services or an E/M and a procedure that are different but necessary to treat the patient’s condition.

This modifier plays a critical role in differentiating when an E/M service is ‘distinct and significant’ from the inherent evaluation included as part of another service on the same day; this could be two E/M services or an E/M service and another procedure. By appending modifier 25 to an E/M code, the provider signifies the billed service is separate and warrants additional reimbursement. Modifier 25 is only ever appropriate in conjunction with an E/M, which is billed by the same physician on the same day as a global procedure or service.

Navigating the Complexities

The bottom line that coders and clinicians usually face is assessing whether an evaluation is truly separate and significant enough to justify the use of modifier 25. Factors considered in the careful assessment process include:

• the decision to perform the additional service,

• the extent (as in the quality of the content leading to more extensive decision making) of the documentation,

• the medical necessity of the service, and

• typical pre-operative and post-operative services.

According to the AMA’s Current Procedural Terminology (CPT) guidelines, certain pre- and post-operative services are included with a procedure and would not count towards a separate E/M services code. Those activities may include but are not limited to the review of the patient’s prior health records, evaluating the problem area to be addressed by another procedure, and reviewing the procedure with the patient or their family/caregiver.

NCCI Guidance

Before we get too overwhelmed, let's break down the evaluation process methodically. The National Correct Coding Initiative (NCCI) Policy Manual provides multiple guidelines on using modifiers.

It’s crucial to diligently adhere to the following rules and never misuse modifiers simply to bypass edits.

Determining Separate

NCCI helps us understand the meaning of the term “separate.” The Medical/Surgical Package section of the Policy Manual states, “Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedural work.” As a result of procedure codes being comprehensive in nature, it is usually unnecessary to bill an E/M. Furthermore, when an additional concern which is not related to the intended procedure is performed, this is separate. The addition of modifier 25 distinguishes the evaluation and an independent, stand-alone procedure. Furthermore, when multiple procedures are performed at the same patient encounter, there may be overlap of the pre-procedural and post-procedure work, which may impact the level of E/M selected.

Determining Significance

How do we determine if a problem is significant? The best direction comes from the AMA’s CPT section guidelines for Preventive Medicine Services. The CPT guidelines state that an abnormality or pre-existing problem might be addressed during the encounter, but if it's insignificant or trivial and did not require the components of a problem-oriented E/M, then an E/M would not be billable. While this language of key components directly applies to the 1995/1997 E/M guidelines, we find the intent is clear – if there was little to no work-up (or medical decision making) for the problem, then billing modifier 25 is not warranted.

Partnering with Payers

Another valuable partner in determining what is significant comes from health plans or, in this example, Medicare Administrative Contractors (MACs). Each MAC may utilize different terms to help understand the meaning of modifier 25. For instance, CGS defines it and then describes it by saying, “above and beyond the service which was already provided or beyond the usual pre/postoperative care that was associated with the procedure performed.” They further state, “Remember when coding for procedures, the E/M visit is “built into” that CPT code. If the patient has a separate and significant problem that does not relate to the procedure billed, then it would be appropriate to bill an E/M visit with the 25 modifier.”[1]

[1] https://www.cgsmedicare.com/partb/pubs/news/2018/01/cope5876.html

A Look at Diagnosis Codes

The application of modifier 25 does not necessitate a change in the diagnosis code; it could be the same or different as the diagnosis captured in other procedure(s) rendered on the same date. For example, perhaps a patient was seen for the follow up of an established condition like hypertension but relayed an issue with headaches requiring additional testing. In such a case, the testing and the E/M with a modifier 25 may be warranted. Alternatively, the E/M service for hypertension may have revealed a completely new diagnosis which may require testing. The testing would have the new diagnosis and the E/M for hypertension. Whether similar or different, the diagnosis codes must be clearly established in the medical record.

Documentation is Critical

While there are no specific CPT documentation requirements when using modifier 25, the old adage remains true: if it’s not documented, it didn’t happen. The provider is expected to thoroughly document the medical necessity of the care rendered; the documentation must support that the level of care provided exceeds the usual preoperative and postoperative work required. To support the usage of modifier 25, the record must reflect the appropriate elements, to include the patient’s history, examination, when performed, and the decision-making process that led to the separate service.

Due to the potential abuse of modifier 25 to gain increased reimbursement, it is likely that claims including modifier 25 will be audited. A complete medical record is imperative for gaining successful outcomes in such audits.

Leveraging All Resources

We talked about NCCI, MACs and CPT definitions, all valuable tools in your understanding and research. AMA also has an article Reporting CPT Modifier 25 (ama-assn.org) that outlines the use of modifier 25 and gives several examples that can be helpful.

Mastering the Modifier

Despite the challenges, it is imperative for healthcare professionals to stay on top of the latest developments and interpretations surrounding modifier 25. Failure to do so can result in coding errors, denied claims, and potential compliance issues.

To truly master the art of modifier 25, one must comprehend the need for medical necessity, follow the established guidelines with precision and intent, meticulously review the documentation, leverage your resources and exercise sound judgment. By adhering to these principles, one can confidently navigate the intricacies of modifier 25 and ensure its proper utilization, thereby upholding the integrity of the coding and billing process.

Ongoing education, open dialogue, and a commitment to staying informed are essential to the appropriate use of this modifier.

Healthcare is an ever-changing scene, and modifier 25 is just one of many areas where the experts at Integrity Advantage can help. Whether you need a hand with training your team on the complexities of Modifier 25, reviewing medical records in an SIU, or focusing on payment integrity, we have the skills necessary to get the job done. And, as a small business, we are able to give you our individualized attention, communicating with you every step of the way and providing laser focused commitment to your team’s unique needs.

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