Medical Coding: Recommendations for Modifier 25 Use

According to CMS rules, both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or the qualified nurse practitioner in the medical record to support the need for modifier 25.

And in a lot of cases, the documentation showed more than one diagnoses where the patient came in with multiple contusions, multiple abrasions. And yet we used the open wound diagnoses to support the open wound repair that was done. The patient had other medical physicians which supported a significant and separate E/M. Therefore, we use the modifier to show that.

The one thing that you must know about modifier 25 is that you need to check to see if the insurance company recognizes modifier 25. For example, Florida Medicaid does not recognize the modifier 25. If you submit the claim, for example, the Florida Medicaid using modifier 25,
you're not going to get the claim paid. It may come back as being denied or appended leading to denied medical coding and billing claims..

Now, some carriers are not going to pay for E/M services reported what a procedure having a global fee period unless CPT modifier 25 is appended to the E/M to designate it as significant and separate. If you submitted in Medicare appeals that the E/M is not significant and separate, you're going to get a claim adjustment code of 97 saying that payment is included in the allowance for another service of procedure.

They may say for the secondary procedure that you preferred which pays a lot less but they're not going to pay for the E/M. There are other remarks code that you may look for is M144. The Medicare guidelines put out a special alert not too long ago. It states when manipulation and E M codes are billed on the same visits, it's necessary to attach a 25 modifier to the E M codes . Now, does this mean they're going to pay for it? Not necessarily. They're just telling you, if you have a provider that's doing manipulation and pay significant E/M code on the same visit, then you then touch modifier 25.

Not so long ago, Aetna is part of that class action lawsuit that they got involved in decided to go back and we look at codes submitted with modifier 25.And what they basically said that we're going to go back and take a look at all the procedures that were submitted with modifier 25. And if a separate procedure is listed on the claim that would consider it for additional payment to ensure appropriate E & M coding .

Blue Cross and Blue Shield, they published what was unacceptable claim submission using modifier 25 which was not an acceptable claim submission. Valid submission using modifier 25, they put down on their website, Sally brought her daughter in for her 3-month preventative exam visit. During the visit, Sally mentioned her daughter was pulling at her ear and thought she might have an earache. This is what we call, “Oh by the way” visit.

This is where you get the patient logging up the front, thus they're coming in for one reason. And when the door is shut behind close doors, that’s when the patient says, “Oh, by the way, doc, I've got this thing in my back that I'd like you to take a look at.”

And the patient may have come in in removal now, all of a sudden, “Oh, by the way, I've got this pain in my lower back where I've got this head problem.” So that could possibly qualify for a significant and separate E/M visit because you're going to have another diagnosis to support the E/M.

Well, in this case, with Blue Cross Blue Shield, a provider examined the ear, we did the three-month preventative exam and he coded it on 99212 using modifier 25 for the exam or the ear ache. Then you did the 99382, the preventative care and then the 90707 which was the immunization you give them.

According to Blue Cross Blue Shield, all services are allowed and eligible for reimbursement. And modifier 25 should be billed using the E/M service. So more Blue Cross Blue Shield have done does allow the use of modifier 25.

Now, Palmetto GBA, another insurance company out there basically talks about CPT and modifier 25. We're on slide number 19 by the way. It goes into the same reasons that's in the back of the CPT and they use the same decision making that Medicare uses to ensure the correct use of modifiers. They're saying that the modifier 25 should not be submitted with E M codes that are for new patients .

It also says that no supporting documentation is required with the claim when modifier 25 is submitted. Most insurance companies don’t require you to submit documentation when you're using modifier 25. Well, you should have the documentation available.

Now, the modifier may be used to indicate that an E/M service was provided on the same day as another procedure that might be bundled under CCI edits, Correct Coding Initiative.

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