Get the Pay-up You Deserve for Those “As Long as I’m Here …” Patients

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Get the Pay-up You Deserve for Those “As Long as I’m Here …” Patients

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Modifier 25 Higher Patient Reimbursement

Too often, a patient schedules a visit for one reason, and then brings in a laundry list of other, unrelated health issues and concerns to discuss with the doctor. You may think this is just a cost of doing business at your practice, but you can be reimbursed for this extra time … if you know how.

A patient comes into your practice for a preventive medicine visit, and while he’s in with the physician, he says, “Oh, by the way …” and starts to talk about this spot on his ear that doesn’t look quite right. Your clinician completes the preventive medicine service, and then turns her attention to the ear lesion. Many providers think they can’t capture the reimbursement for the extra time spent with the patient, but may not be the case.

You can use modifier 25 to designate a significant, separately identifiable evaluation and management (E/M) service provided by the same physician to the same patient on the same day as another procedure or service. And knowing what constitutes “a significant, separately identifiable” E/M service is the key.

To make this decision, ask yourself a few questions:

  • Did the physician perform and document the key components of a problem-focused E/M service for the new complaint (i.e. history, exam and medical decision-making)?
  • Would the service provided to address the new complaint constitute a billable service if taken alone?
  • Does the complaint portion of the service address a different diagnosis?
  • If the diagnosis is the same, did the physician perform extra work that went above and beyond that typically associated with the scheduled service?

If you can answer yes to these questions, then you can likely report an additional E/M office visit code (99211-99215) appended with modifier 25. This will allow you to capture additional reimbursement for the extra time the physician spends with the patient.

Taking the earlier example, the physician completes the preventive medicine exam, and then documents a problem-focused history and examination and straightforward medical decision-making to address the new complaint. In this case, you would be able to report not only the preventive medicine service, but also the part of the service devoted to the patient’s ear lesion with 99212-25.

And this is just one example. Knowing when you can capture your providers’ additional E/M work and report it appropriately with modifier 25 can meaningfully impact your practice’s bottom line.


Take Aways:

  • Use modifier 25 to capture revenue for significant, separately identifiable E/M visits.
  • Before you use modifier 25, make sure your provider performs and documents the key elements of a separate E/M service.
  • You can use modifier 25 only with E/M codes.