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    When can modifier –25 be used with an E/M code?

    Ray Painter, MDRay Painter, MD Mark PainterMark Painter

     

    We were told that we could not use modifier –25 on an evaluation and management (E/M) code unless we have a new diagnosis. Is this true?

    No, this is not true for Medicare, nor is it true from a CPT standpoint. However, some payers will deny an E/M code with a modifier 25 if both the E/M code and the procedure or service reported on the same date have the same diagnosis code. Of course, some payers will categorically deny any number of services that are correctly reported. We would encourage you to report correctly and, as always, appeal wrong denials, making sure that your documentation supports the services billed.

    The instructions from CMS to the carriers are very clear in the following excerpt from the “Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners 30.6.6 - Payment for Evaluation and Management Services Provided During Global Period of Surgery”:

    “A/B MACs (B) pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier –25 is added to the E/M code on the claim.”

    Also by the Painters - Medicare final rule: Urologists’ pay set to decrease (again)

    The instructions from the CPT manual are also fairly straightforward and are included in the full definition of modifier –25 included below (emphasis added in italics).

    “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.”

    Remember that even though a new diagnosis is not required, the definition of the modifier and the rules surrounding the use of the modifier –25 require that the E/M service is significant and separately identifiable. This means that the documentation for the visit must clearly reflect E/M services provided on the same date cannot be services that are normally provided in conjunction with the service.

    As an example, a patient is scheduled for a cystoscopy. The global service package would include making sure the patient is fit to have the service provided including any history, physical examination, and medical decision-making related to deciding to proceed with the service.

    What if the cystoscopy revealed a bladder tumor of unspecified behavior? If documented, the time spent discussing the treatment options and recommendations could be reported separately under an E/M code with modifier –25 even though both the cystoscopy and E/M would be reported with the same Dx code, as treatment of the finding is not a part of the diagnostic cystoscopy.

    Next: "Every part of E/M coding counts and is dependent upon both circumstance... and medical necessity."

    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.

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