Usage of Modifier 25 - when to use and tips

When should CPT modifier -25 be used?

Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately identifiable evaluation and management (E/M) service. It should be used when the E/M service is above and beyond the usual pre- and post- operative work on a procedure with a global fee period performed on the same day as the E/M service

• The Centers for Medicare & Medicaid Services (CMS) has clarified the documentation requirements and policy requirements for the use of CPT modifier -25 used with E/M services. Please refer to the manual attachment to CR5025, The Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.6, for revisions regarding the use of CPT modifier -25.

• Physicians and qualified nonphysician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.

• Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately identifiable evaluation and management (E/M) service. It should be used when the E/M service is above and beyond the usual pre- and post- operative work of a procedure with a 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 is added to the E/M code on the claim.

• Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient’s medical record to support the need for Modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim.

• Your carrier will not retract payment for claims already paid or retroactively pay claims processed prior to the implementation of CR5025. But, they will adjust claims brought to their attention.

• Carriers will not pay for an E/M service reported with a procedure having a global fee period unless CPT modifier -25 is appended to the E/M service to designate it as a significant and separately identifiable E/M service from the procedure. Such payment will be denied with the following messages:

Billing modifier 22 - Usage and coding tips

Modifier 22 INCREASED PROCEDURAL SERVICES

When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.

Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.

Using the Modifier Correctly

• Modifier 22 is appended to the basic CPT® procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of modifier 22 allows the claim to undergo individual consideration.

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• Modifier 22 is generally not appended to a radiology code. If a rare circumstance does occur, submit detailed documentation with a cover letter from the radiologist or other provider.

• The frequent reporting of modifier 22 has prompted many payers to simply ignore it.

• Modifier 22 is used with computerized tomography (CT) numbers when additional slices are required or a more detailed examination is necessary. However, this is subject to payer discretion. Many payers will not allow additional reimbursement for additional CT slices.

Incorrect Use of the Modifier

• Appending this modifier to a radiology code without justification in the medical record documenting an unusual occurrence. Because of its overuse, many payers do not acknowledge this modifier.

• Using this modifier on a routine basis; to do so will cause scrutiny of submitted claims and may result in an audit.

• Using modifier 22 to indicate that the radiology procedure was performed by a specialist; specialty designation does not warrant use of modifier 22.

• Using modifier 22 when more x-rays views are taken than actually specified by the CPT code description. This is incorrect, especially when the code descriptor reads “complete” (e.g., 70130, 70321, 73110, etc.). Complete means any number of views taken of the body site.

Coding Tips

• Using modifier 22 identifies the service as one that requires individual consideration and manual review.

• Overuse of modifier 22 could trigger a payer audit. Payers monitor the use of this modifier very carefully. Modifier 22 should be used only when sufficient documentation is present in the medical record.

• A Medicare claim submitted with modifier 22 is forwarded to the payer medical review staff for review and pricing. With sufficient documentation of medical necessity, increased payment may result.

Modifier 22 (Unusual Procedural Services)

Tufts Health Plan requires documentation when claims are submitted with modifier 22 (unusual procedural services). Claims submitted without additional documentation are not considered for additional compensation. Clinical documentation must indicate one of the following:

** Excessive blood loss for the particular procedure performed

** Extensive, well-documented adhesions present with an abdominal surgery and requiring minimum of 45 minutes to lyse

** Presence of an excessively large surgical specimen (tumor)

** Trauma so extensive that the particular procedure and complication is not billed as separate and distinct procedures themselves

** Other pathologies, tumors and malformations that increase the complexity of the procedure

** Extended anesthesia is identified (anesthesia record must be submitted)

Do not submit modifier 22 if you are reporting any of the following:

** Increased complexity due to a surgeon’s choice of approach

** Describing a re-operation

** Describing a weight reduction surgery

** Describing the use of robotic assistance

** An unspecified procedure code

Usage of Modifier 25

Most used Modifier 25 - is Significant, Separately Identifiable Evaluation andManagement Service by the Same Physician on the Same Day of theProcedure or Other Service.

Key Points to Remember:

When using this modifier, Medical Documentation is vital and essential to support medical necessity. This must be well-documented on the patient's medical record.

You are using Modifier -25 because you are stating that the Evaluation and Management Service is separate from that of the procedure performed on the same day.

Append this modifier if and only if it is a medical necessity and is a separately identifiable E/M service of that with the procedure done on the same day.

Sample Encounter 1:

The patient came in to the office with a chief complaint of entire body ache. She also present with an abscessed toe nail which she claims started after she cut her toe nails using a toe-nail cutter 2 days ago. The physician then added the incision and drainage procedure performed on the abscessed toe nail.

Codes:

99212-25

18060

Sample Encounter 2:

The patient came in to the office for her scheduled 2nd therapeutic knee injection. On the same day, she presented herself as complaining with neck pain that has been bothering her sleep for the past 3 days. The physician then added a separate E/M service. 

Codes:

99213-25

20610

CPT modifiers 25 question - where and when to use

If you perform a preventive care service and an immunization simultaneously, would you apply a modifier? Example: Providing an Annual Wellness Visit (AWV) and a preventive vaccination.

2A: The AWV is not an E/M service; therefore, E/M modifiers do not apply. However, you should ensure documentation is present in the medical record to support the separate immunization.

 If a new patient presents to a practice and ends up having a joint injection during that same visit, is the E/M billable? Would I use the 25 modifier?

3A: If the patient is not coming specifically for a joint injection, then 'No,' the modifier is not needed since the patient is being seen as a new patient. The modifier 25 is not needed with an initial E/M service code.

However, if the patient is established and presented for an E/M service only, and the joint injection was performed as a result of the E/M, then 'Yes,' you can bill the E/M and apply modifier 25 as long as documentation can be provided showing the medical necessity for the services

If we provide a preventive immunization (e.g., pneumococcal vaccination), should we use modifier 25?

4A: If an established patient is not coming in specifically for the preventive immunization, then 'Yes' you could apply modifier 25 to the E/M service as long as documentation can be provided showing the medical necessity for the services.

 If an initial consultation and/or follow-up office visit requires a chest X-ray, pulmonary function test (PFT) or 6-minute walk (stress test) for the purposes of evaluation, would the E/M service require modifier 25?

5A. Again, if the rationale for why the patient is there is the X-ray, PFT or stress test, then a separate E/M wouldn't be payable. However, if the patient is there for an initial consultation and the X-ray or PFT is then ordered and performed, then modifier 25 may be billed as long as documentation can be provided showing the medical necessity for the services.

 Is there a penalty when modifier 25 is inappropriately applied to a new patient visit code?

6A: Currently, there is no editing to prevent the modifier 25 from being billed with initial visits as previous guidelines did require the modifier. However, since the modifier is not required, future editing enhancements could cause the claim to be returned as unprocessable for an invalid modifier.

 If the patient presents with joint pain and has a joint injection on the same day, can we bill for both the office visit and the injection or would the documentation requirements have to be met?

7A: If the patient is new and is not coming specifically for a joint injection, then 'No,' the modifier is not needed. Since the patient is being seen as a new patient, the modifier 25 is not needed with an initial E/M service code.

However, if the patient is established and presented for the E/M service only and the joint injection was performed as a result of the E/M, then 'Yes,' you can bill the E/M and apply modifier 25 as long as documentation can be provided showing the medical necessity for the services.

When an inpatient is in a critical care unit and the physician inserts a Swan-Ganz during the visit, do we append a modifier 25 to the Current Procedural Terminology® (CPT®) code 99291?

9A. Regarding critical care services, if the services are separately identifiable from why the patient is in the hospital, then 'Yes,' the code can be billed with modifier 25 as long as documentation can be provided showing the medical necessity for the services.

Services such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter e.g., Swan-Ganz (CPT code 93503) are not bundled into critical care codes. Therefore, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier 25.

However, if the critical care is being provided due to the rationale for why they are in the hospital, then everything would be rolled up under the hospital billing.

How significant must the change in treatment plan be? 

Common scenario: Patient with known arthritis being managed conservatively presents complaining of increasing pain and the physician does a steroid injection to knee.

10A. If the patient has been on a specific plan regiment for a while (ex.: 3- to 6-months) and the plan changes significantly (arthritis gets extremely exacerbated or detrimentally worse), you can bill the modifier 25 as long as documentation can be provided showing the medical necessity for the services.

 A patient comes in for a post-operative visit within the global days for sinus surgery and has complaints of sinus pressure and is sneezing. Would this be considered related or unrelated? Does this allow for an E/M visit with a modifier 24?

11A. If the physician determines the pressure and sneezing is unrelated to the surgery and provides the rationale in the records, they can bill for an E/M with a modifier 24 as long as documentation can be provided showing the medical necessity for the services. Documentation will likely be requested.

If we provide an outpatient surgery on a patient (ex: 90-day global period) and admit the patient after surgery, can we bill for the admission, subsequent hospital days, and the discharge?

12A. Depends on whether the admission is related to the surgery or not. Here are some examples of services not included in the global period:

• Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care.

• Visits or hospitalization unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.

• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery

Use of modifier 24 will require documentation to be reviewed. The separate services may be billed as long as documentation can be provided showing the distinction and medical necessity for the services