Medical Billing Modifier 25
Summary:
We attempt to help clarify the usage and clear up confusion in regards to using Medical Billing Code Modifier 25 in this and future blogs.
Modifier 25 Background
Modifier 25 can be used for outpatient, inpatient, and ambulatory surgery centers.
Modifier 25 can be used for critical care codes and emergency department visits and services.
When two separate services are billed by the same provider to the same patient on the same day, you may elect to choose Modifier 25, but here are some tips to ensure you either submit the claim correctly (Provider side), or you review the claim correctly (Payer side).
When and Where are Modifiers used?
Think of it as storytelling. When a patient comes in for something and something additional happens, you need to look at applying the right modifiers. Modifiers should be applied to the E/M codes, aka the reason for the initial visit to the outpatient, inpatient, or ambulatory center.
Quick Checklist for Modifier 25
Checklist:
- Is the E/M code clear and correct for the initial reason for patient care to be billed?
- Is there a separately identifiable evaluation?
- Is it minimal or significant? Maybe you need a different “bundled code.”
- Is the additional separate service clarified by a separate ICD-10?
- Did the patient require a significantly identifiable E/M service above and beyond the original service?
- Is both the E/M and procedure both properly documented?
- Did you go above and beyond?
Stress Test Example
A patient comes into her Cardiologist for chest pains. Provider reviews the history and meets with the patients, and due to a history of hypertension and cholesterol orders a Stress Test to occur that same day.
What are the codes?
- 99214 for the consult with modifier 25
- Modifier 25 stops the bundling of 99214 and 93015 and separates them.
- 93015 for Stress Test
When would the Cardiologist not use a Modifier for this Scenario?
If the provider didn’t perform the stress test, that’s fraud. Only bill for what you performed.
Checkup turns into a Pain Complaint
A patient comes into a follow-up with his primary care doctor in regards to refills for his type II diabetes. However, during the visit, the patient limps into the office and has a 8/10 foot pain complaint. Upon inspection the Doctor finds the patient had stepped on a shard of glass and the glass is embedded under his skin. The Doctor removes the glass safely and then proceeds to address the refills and medication therapy management protocols.
What are the codes?
- 99213 for the consult with modifier 25
- Modifier 25 stops the bundling of 99214 and 20520 and separates them.
- 20520 for Removal of foreign body in muscle, tendon sheath; simple.
Why?
It’s within the Global 10-day limit and the provider properly documented they went above and beyond. Plus the payer will likely be happy the provider was able to remove the glass and the Payer wasn’t charged an in-patient hospital and the ambulatory transportation fees.
When would the Doctor not use a Modifier for this Scenario?
If the provider was unable to remove the shard of glass, or felt it too extreme to perform in-office (outpatient), and had to send the patient to the ER, the Doctor would only bill for 99213. Why? Because the DR didn’t remove anything, he/she failed to “provide service.”
SUMMARY:
Modifier 25 is simple to understand. The patient came in for one thing and something important needed to be addressed that day and the Doctor was able to handle it by going above and beyond.
As new AMA and CMS updates come our way you can find them here in our blog or you can simply sign up for iVECoder for providers (CLICK LINK HERE), or get a FREE consultation on our Virtual AuthTech and VE programs for payers (CLICK HERE).
Our History and Credibility in Reporting this Information:
For over 30 years, PCG Software Inc. has been a leader in AI-powered medical coding solutions, helping Health Plans, MSOs, IPAs, TPAs, and Health Systems save millions annually by reducing costs, fraud, waste, abuse, and improving claims and compliance department efficiencies. Our innovative software solutions include Virtual Examiner® for Payers, VEWS™ for Payers and Billing Software integrations, and iVECoder® for clinics.
