Understanding When to Use Modifier 25 for E/M Services
Modifier 25 is defined as a 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.
Often questions are posed regarding whether to bill an E/M visit on the same day as a procedure and/or other services with modifier 25.
Why is the patient being seen?
Were the physician's or other qualified health care professional's evaluation and management of the problem significant and beyond the normal preoperative and postoperative work?
Yes, an E/M may be billed with modifier 25
No, it is not appropriate to bill with modifier 25
Does the complaint or problem stand alone as a billable service?
Yes, an E/M may be billed with modifier 25
No, it is not appropriate to bill with modifier 25
Did the physician perform and document the key components of an E/M service for the complaint or problem?
Yes, an E/M may be billed with modifier 25
No, it is not appropriate to bill with modifier 25
Is there a different diagnosis for a significant portion of the visit? Or if the diagnoses are the same, was extra work above the and beyond the usual preoperative and postoperative work associated with the procedure code?
Yes, an E/M may be billed with modifier 25
No, it is not appropriate to bill with modifier 25
Are there signs, symptoms, and/or conditions the physician or the other qualified health care professional must address before deciding to perform a procedure or service?
Yes, based on the documentation, an E/M service might be medically necessary with modifier 25
Was the procedure or service scheduled before the patient encounter?
Yes, it is not medically necessary to bill for an E/M
Is there more than one diagnosis present that is being addressed and/or affecting the treatment and outcome?
Yes, bill the procedure code and the E/M with modifier 25
No, it is not appropriate to bill with modifier 25
Example:
An established patient sustained a severe laceration to the scalp. Before suturing the laceration, the physician performed and documented a comprehensive history and exam to determine if the patient sustained neurological damage.
The physician then performed a 3.0 cm intermediate repair (12032) to the scalp.
The proper billing would be procedure code 99215 25 and 12032.
Based on the signs, symptoms and conditions documented, the physician went above and the normal preoperative work.
Source: Novitas
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