Modifier 25 — Defending a "Significant, Separately Identifiable Service"
By Karna W. Morrow
Think about the last time you attached modifier 25 to an Evaluation and Management (E/M) code. What were the circumstances? It was a new patient. The procedure or service was not planned. The provider documented each of the key components in addition to documenting the procedure. The payor denied the original E/M claim. Circumstancesmay warrant both a visit and a procedure or service on the same date of service, but when both services can be charged can be difficult to determine.
The CPT® Manual defines modifier 25 as follows:
Significant, separately identifiable evaluation and management services by the same physician or other qualified healthcare professional on the same day other procedure or other service: It may be necessary to indicated that on the day a procedure or service identified by a CPT®code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative or postoperative care associated with the procedure that was performed.
For coding purposes, the decision point lies in the phrase "above and beyond the usual preoperative or postoperative care." Does the history of the present illness and/or physical exam include any data beyond details specific to the condition for the procedure?
For example, if a patient trips, falls, and injures his knee, requiring sutures, the patient is seen in the emergency department and the wound is sutured. If the evaluation of the patient is focused on the injured knee, only the simple repair of the skin wound is reported.
However, if a patient becomes dizzy, falls, and lacerates his head, the urgent care physician fully evaluates the reason for the patient's dizziness in addition to suturing the head wound. An E/M with modifier 25 would be reported in addition to the wound repair procedure code.
The Emergency Medical Treatment and Labor Act (EMTALA) does require a certain level of medical screening for each encounter or exam. Modifier 25 guidelines are not written or applied according to specialty. The American College of Emergency Physicians FAQ states:
An E/M service that represents a separately identifiable service (e.g., to rule out additional injuries, screening for physiologicetiology, or manage an illness) can always be reported with a procedure. If, however, performance and documentation only addresses the surgical procedure and does not provide an overall evaluation of the patient's condition, history of injury, review of related and/or additional systems, comorbidities, allergy status and management options, only the surgical procedure may be reported.
CPT® Assistant (March 2012) provides the following instructions for reporting a significant, separate encounter with modifier 25:
Was the physician's evaluation and management of the problem significant and beyond the normal preoperative and postoperative work? If yes, then an E/M service may be reported with modifier 25 appended. If not, it is not appropriate to report an E/M service with modifier 25 appended, as the service is included as part of the surgical package.
For example, a patient is being followed by a dermatologist for rosacea. During a scheduled visit to reorder medication for the rosacea, the patient mentions she has noticed a new pigmented lesion on the right upper thigh area. The physician evaluates and excises this new lesion. Both an E/M with modifier 25 and the excision of the lesion can be reported. The evaluation of the rosacea would be above and beyond the clearance necessary for the excision.
The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) Policy Manual to promote consistent and correct coding, and reduce inappropriate payments. Chapter 1 of this guide states:
In general, E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.1
Chapter 9 of the National Correct Coding Initiative Policy Manual for Medicare Services adds:
As a rule, if the medical decision making that evolves from the procurement of the information from the patient is limited to whether or not the procedure should be performed, whether a comorbidity may impact the procedure, or involves discussion and education with the patient, an evaluation/management code is not reported separately.2
The criteria for a physician or hospital to bill a visit in addition to another service on the same day are essentially the same.
The Medicare Benefit Policy Manual, Chapter 6, defines a hospital technical visit this way:
A hospital outpatient "encounter" is a direct personal contact between a patient and a physician, or other person who is authorized by State licensure law and, if applicable, by hospital or CAH staff bylaws, to order or furnish hospital services for diagnosis or treatment of the patient.3
As indicated, the definition of the hospital technical service is not considered to be a "nurse visit"; nurses are not separately reimbursed for patient visits in any practice setting.
CMS cautions that "billing a visit code in addition to another service merely because the patient interacted with hospital staff or spent time in a room for that service is inappropriate."4
There are also Medicare instructions specific to reporting a visit in addition to a drug administration service:5
Hospitals are reminded to bill a separate Evaluation and Management code (with modifier 25) only if a significant, separately identifiable E/M service is performed in the same encounter with OPPS drug administration services.
Before attaching modifier 25 to the E/M, ask yourself what specific data elements or lines within the documentation support the above and beyond requirement? The documentation from the physician should be as clear as possible, especially in the assessment and plan, so that a reasonable determination can be made. With the many auditing entities watching for mistakes in this area, it is worth the extra effort to make sure all compliance guidelines are being followed.