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Key to Using Modifier 25? Separate History and Exam

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Key to Using Modifier 25? Separate History and Exam

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Using modifier 25

With the new 2021 E/M guidelines in effect, payers and auditors have made it clear that they’ll be closely scrutinizing E/M claims more than usual—this includes the modifiers appended to them as well.

One of the murkiest modifiers continues to be 25 (a significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of a minor procedure). This is compounded by the differences in the new 2021 E/M guidelines and modifier usage 25 rules.

So, if you want to get paid for the extra E/M services you provide by using modifier 25, you must master the finer points of this confusing code.

E/M Rules Have Changed, but Modifier 25 is the Same

New 2021 E/M rules state that patient history and exam are no longer counted towards scoring your level of medical decision making (MDM). Because of this rule change, you may assume that it will be easier to bill an E/M service separately from a minor procedure that was performed on the same day.

This is not true and will result in your claims being denied.

Why? To use modifier 25, your documentation must still support billing an E/M code separately from the procedure provided on the same day. Even if MDM is the basis for choosing an E/M code, you must still document a medically necessary history and exam. Just because the history and exam don’t count in terms of scoring the level of MDM, that doesn’t mean that your doctor is going “above and beyond” by providing them.  The  E/M service is still bundled with the procedure.

You must be able to look at your documentation and identify a history and exam separate from those included in the procedure. If you can’t, using modifier 25 is not appropriate.

When Is Using Modifier 25 Appropriate?

The simplest example for modifier 25 is when your patient requires an evaluation for a problem that is completely unrelated to the procedure they came in for. It’s pretty easy to identify when this occurs. But there are a few other situations that warrant using modifier 25 that are a bit trickier:

  • “Above and beyond” what is typically required as part of a minor procedure.

    CMS Example:
    A patient presents with a head laceration. Your physician determines sutures are necessary. The E/M service for this procedure (which includes an exam and decision for treatment) is not separately billable. However, during the visit the patient also complains of nausea. Based on symptoms from the head laceration, your doctor determines that a full neurological exam for head trauma is medically necessary.

    Result: Due to the added symptom and extended services provided
    , appending modifier 25 to the E/M code is appropriate. The neurological exam is “above and beyond” what is typically required to treat a laceration.
  • E/M service prompts a minor procedure at that same visit.

    Example #1:
    An existing patient presents with shoulder pain. The treatment plan includes activity modification with joint injection, if necessary. At a subsequent visit, the patient presents for the injection. Your physician performs a brief exam to clear the patient for the injection.

    Result: The brief exam is considered normal perioperative care, and that E/M service is not separately billable.
    Example #2: A new patient presents with complaints of significant shoulder pain. In addition to the medically appropriate history and exam, your physician orders and reviews x-rays, discusses treatment options, and creates the same treatment plan as the patient in example #1. However, this patient decides to go ahead with the injection at that same visit instead of waiting for a subsequent appointment.Result: This E/M service has gone above and beyond what’s required for a simple injection. Your physician would not normally order and review x-rays or discuss treatment options if a patient presented for a scheduled injection where the decision for the procedure had been made at a previous appointment. Modifier 25 is appropriate as long as your documentation supports the medical necessity and indicates that the decision for the procedure was made during that same visit.
  • Exacerbation of symptoms from an existing condition that requires a separate evaluation.

    A child with eczema presents for an annual well visit. The eczema has worsened since the last visit, prompting a new evaluation and updated treatment plan with new medication.Result: A new evaluation of the eczema, updating the treatment plan, and discussing new medication goes above and beyond what a well visit requires. Modifier 25 is appropriate as long as the eczema exam and discussion is documented separately from the well visit. If the eczema was stable and did not need evaluation, modifier 25 would not be appropriate.

Ensure Separate Payment with Separate Documentation

When using modifier 25, the documentation must support the distinct, separate, and significantly identifiable nature of the E/M. Some documentation tips to justify modifier 25 is separate include:

  • Your documentation for the separate E/M service should not include any of the typical pre or post service work associated with the performed procedure.
  • You must document the procedure (with included E/M services) and the significant, separately identifiable E/M service separately in the patient record.
  • Avoid mixing both services together in one entry.
  • A great way to separate documentation is to use a heading or sub-heading. This visual separation also makes it easier for coders to pick out separately billable E/M codes, and avoid missing out on that well-deserved reimbursement.

Misusing modifiers (especially modifier 25) can lead to denied claims, reimbursement overpayments and your practice getting audited (which you certainly don’t want).  Getting audited means that auditors can dig through your records for years and come up with a variety of violations resulting in significant fines.

To get more on how to appropriately apply modifier 25 and other E/M modifiers, check out Kim Huey’s upcoming 60-minute online training on Tuesday, March 16, at 1 pm ET.  This training will provide you with clear step by step instruction on how to ensure you are paid for more of the services and that your claims are correct, supported and audit-proof.

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