Coding Updates: Changes in Modifier 25



Modifier 25 is for significant, separately, identifiable E/M service by the same urologist on the same day that he performs a procedure. Read this article and get tips from our expert provided in a medical coding conference to know more about the correct use of modifier 25.

A change was added to the descriptive for modifier (inaudible) same for significant, separately, identifiable none E/M services look at and use modifier 59. Now, remember, modifier 25 can only be used on the day in which an E/M service is provided at the same time that there is a procedure or other service. The modifier 25 gets attached to the E/M code.

The office of the inspector general several years ago, indicated to medicine that the modifier 25 was probably being used incorrectly on over a third of the claims in which it was used. And CMS then declared that at that same time, they have probably paid $538 million in improper payments to improperly used modifier 25. So, OIG and Medicare is always scrutinizing the use of modifier 25.

According to the modifiers coding updates, you must use modifier 25 when the patient's condition required the significant and separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that you did.

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Let’s look at CPT modifier 25 in more detail. We have indicated that it should be attached to an E/M service when the procedure performed at the same time is a zero or 10-day global procedure. Let's look at some examples of when you would be using modifier 25 correctly.

If you have two existing unrelated problems, in other words, you have a patient that you've been following for lower urinary tract obstructive symptoms and you have them on an a alpha blocker and finasteride and he's doing well and he comes in to see you, you know, once or twice a year. And you examine him and he's doing well and his prostate is unchanged.

But on this visit, you do notice that now he shows microscopic hematuria, 599.7. And you decide to do a cystoscopic examination. Now, in this billing, you have two co-existing unrelated problem. For the office visit with modifier 25, your diagnosis should be BPH with obstruction. Now, for this cystospcopy, this is a non-related problem with the diagnosis of micro-hematuria, 599.7. You should be paid for both services.

Now, another medical coding example is where the patient's particular problem prompts you to do an E/M service and examination and also prompts you to do a procedure. Now, let's look at someone that comes in your office with gross hematuria, 599.89. Does that prompt the urologist to do an examination? Certainly it would. And does it prompt the urologist to do a cystoscopic examination? Many urologists would do it at the same encounter.

Now, in this particular case, you may use the same diagnosis for both the E/M visit and for the procedure, the cystoscopic examination so that you would bill for the E/M visit, 599.89 and for the cysto 599.89 gross hematuria. That certainly is acceptable for Medicare.

Now, let us warn you that several private carriers who do not like to pay you both for an E/M service and a procedure on the same day will want you to give them – if you want to be paid two different diagnoses. So, the first diagnosis for your E/M service with modifier 25, you would bill gross hematuria as the reason for your examination, 599.89 as per the medical coding rules.

And then, for your cysto, give them another diagnosis. Now, the other diagnosis can be what you found in the bladder when you did use cystoscopic examination, your postoperative diagnosis. Whether the patient has hemorrhagic cystitis or a blood of tumor 188.2 or maybe he had a bladder stone causing the bleeding 594.1.

The third clinical example would be a patient who comes in, let us say to have a follow-up cystoscopic examination and you're following this patient and surveillance cysto because of previous bladder tumors. You do your cystoscopy and this cystoscopy is negative.

Now, since this patient's visit was a planned cystoscopy, that visit should not be billed more than the 52000 as per the recent medical coding guidelines. However, let us say, under the same circumstances, you find a bladder tumor and now you bring the patient into your consulting room and you speak to him in coordinating counseled him and coordinated care for the removal of this tumor, that can be billed as an E/M service basing the billing on time during which you face to face spoke to the patient and counseled and coordinated to care for the treatment of the newly found bladder tumor.

Your cystoscopy, you could bill 52000 in this case and the reason, history of bladder tumor, V10.51. And then, when you spoke to him about the bladder tumor face to face, you could bill your E/M service with modifier 25 on time and the diagnosis will be bladder tumor 188.2. Using modifier 25 will not affect the payment of the E/M service nor the procedure.

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