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3 Modifier 25 Best Practices to Keep Your E/M Pay Flowing

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3 Modifier 25 Best Practices to Keep Your E/M Pay Flowing

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Modifier 25

Every minor procedure your providers perform includes an inherent evaluation and management (E/M) portion factored into the reimbursement for it. But when you go beyond that cursory E/M work, you should be able to collect for the extra time your provider spends — and that’s where modifier 25 comes in.

Although modifier 25 represents a common and helpful way to collect for the E/Ms you perform along with minor procedures, it’s also poorly understood, and is the target of many auditors’ investigations.

To ensure that you’re using modifier 25 properly, check out three best practices so you can keep collecting for your services.

1. You Can Only Append It to the E/M Code

If you perform a minor procedure along with a significant, separately identifiable E/M service, you can append modifier 25 to the E/M code for that date of service. While some coders erroneously add modifier 25 to the procedure code, that’s incorrect coding.

For example, suppose you see a patient for an incision and drainage (I&D) of a subcutaneous cyst on the hand. While the patient is there, they also complain of a new rash on their leg, which the provider evaluates. She calls in a prescription for a topical cream to treat the leg rash, and then performs the I&D on the hand. She reports 99213-25 for the leg rash evaluation, along with 10061 for the I&D to the hand.

It isn’t necessary to have separate diagnoses when using modifier 25, but if you do have two different diagnosis codes you can report, always link them to the correct, corresponding CPT code on your claim form.

2. Know What’s ‘Significant’ and ‘Separately Identifiable’

Some practices avoid reporting E/M services with minor procedures because they aren’t sure whether they can justify what’s significant or separately identifiable. In short, you must be able to look at the provider’s documentation and visually identify a separate evaluation that stands alone as a billable service, beyond what would normally be performed as part of the procedure.

If you don’t see documentation to support a standalone E/M service for a medically necessary complaint, then you probably cannot justify reporting the E/M with modifier 25.

3. Identify ‘Minor Procedures’

Remember that you should only use modifier 25 when your E/M service happens on the same date as a minor procedure. These are procedures that have a 0- or 10-day global period. If your procedure instead has a 90-day global period, you’ll want to append modifier 57 instead of modifier 25.

Interested in boosting your modifier skills to keep pay flowing at your practice? Expert Michael Strong, MSHCA, MBA, CPC, CEMC can help during his 60-minute online training, Master Coding Modifiers and Uncover Unclaimed Revenue. Register today!


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