Ask an Auditor Anything: Modifier 25, Simplified

Ask an Auditor Anything: Modifier 25, Simplified

Posted by Lori A. Cox
Feb 26, 2020 9:44:16 AM

Recently, we hosted a webinar titled, Decoding the Mysteries of Modifier 25, where I walked through the complexity and uncertainty that has forever shrouded Modifier 25 in mystery. There was so much to unpack on this perplexing modifier that I ran out of time, leaving no room for a Q & A session. So, I promised those in attendance that I would answer (most) of your questions in a follow-up blog post. And here you have it: the answers to some of the most pressing questions many of you have around Modifier 25. 

For those of you who weren’t in attendance but have still more questions on Modifier 25, feel free to post them in the comments section below where I, or anyone from our audience, can help you find the answers you’re looking for.

Question 1 from Tori A:

Could you mention the use of modifier 25 on initial hospital visits the same day as a minor procedure? For example billing 99222-25?

Answer 1:

The same rules apply, the initial H&P must be separately identifiable, which it usually is. A minor procedure shouldn't warrant a hospital stay, so it would be above and beyond the normal global procedure.


Question 2 from Usman B:

In case of Sick and Preventive visit on the same day. Modifier 25 should be billed with Regular E&M 99213 or preventive E&M (e.g.99386)?

Answer 2:

Append modifier 25 to the sick visit (99213) since it has the lower RVU value.


Question 3 from Mona B:

Could you address the common use of the 25 modifiers, perhaps by the urology specialty which often see patients directly after cystoscopy procedures to further coordinate care and or counsel patients based on findings of the procedure?

Answer 3:

Receiving the results of the cystoscopy is included in the procedure, so look for anything done above and beyond that.


Question 4 from Becky D:

Billing Outpatient Cardiology Clinic in CAH. We do an E/M level for the room and the physician will do an EKG in addition. Is modifier 25 appropriate for this? How about when we add an Echocardiogram to the mix?

Answer 4:

Yes, modifier 25 is appropriate, as long as the documentation supports the E/M service.


Question 5 from Hilary F:

A patient comes in for chemotherapy infusions. The doctor was called in the room to counsel the patient on medication dosage. The patient had an allergic reaction to a chemo drug and needed Benadryl. The patient became sick during the infusion and the doctor was called to examine the patient and provide treatment, or if they needed to be admitted. Once the provider documents those encounters, should an E/ M be used with modifier 25?


Yes. This is above and beyond normal chemo.


Question 6 from Donna G:

Does the XXX global signify that ALL procedures can have an E/M billed with modifier 25?


No. There still must be a medically necessary E/M documented in order to bill.


Question 7 from Ann G:

Do you recommend a provider create two progress notes for a preventive visit with a sick visit?


While that would be great from an auditor and payer standpoint, it isn't always easy for providers to do that depending on their EMR.


Question 8 from Beth H:

With the preventive medicine visit the patient has WCC done and nasal congestion and cough. Can you then add the 99213-25?


Self-limited or minor problems likely should not be billed as a separate E/M unless they require Rx, additional work-up, or a significant amount of time.


Question 9 from Karen J:

For Oncology visits on the same day as chemo or injection and the MD is ordering PET/CT restaging scans to evaluate progression or improvement of the disease/response to treatment. In your opinion would this be considered above and beyond? (I know in general complications from chemo that are being treated/managed or unrelated diagnosis is generally reportable with 25 mod.)


Yes, restaging scans are outside of the normal chemotherapy procedures.


Question 10 from Grace J:

The Medicare LCD indicates that an E/M service is allowed with routine foot care procedures when a patient has known Loss of Protective Sensation and the patient has not been seen for at least 6 months. On the basis of the LCD, when a NEW patient presents, is it appropriate to charge a new patient E/M with a 25 modifier in order to determine IF the patient has LOPS and/or comorbidities?


Yes, that would be above and beyond routine foot care.


Question 11 from Meredith L:

Our providers carry a lot of information over from previous visits. When we audit, we only have that one progress note. How is an auditor to know what is relevant to that visit only?


As auditors, we really cannot determine medical necessity. If copy/paste is an issue, an audit should be completed specifically focusing on this issue. Learn more about the dangers of copy/paste here.


Question 12 from Elizabeth L:

Can you bill an E/M with an OMT? What if the patient keeps falling, or keeps hurting themselves, and comes back every month for OMT & E/M?


Yes, you can bill them both, as long as the E/M is separately identifiable. If the patient is only coming in for OMT, then no E/M would be billable unless the provider is evaluating to see why the patient keeps falling.


Question 13 from Lori M:

Could I please get your input on a scenario? A brand new patient presents to a dermatologist due to a lesion. The dermatologist evaluates the lesion, discusses the History with the patient of discomfort and redness at the lesion, discusses the possible differential diagnoses as well as potential treatment plan options. The dermatologist and patient agree to proceed with excision of the lesion. Is that E/M work still considered to be bundled into the excision procedure? If a script is provided, is that often a trigger that a separate E/M is justified?


Discussing differential DX and TX options would possibly qualify for a separate E/M. The documentation really needs to support the visit separate from the lesion removal. Prescribing meds does not automatically qualify for an E/M.


Question 14 from Lori M:

Could you please comment on another scenario? A brand new patient presents to ortho due to knee pain. Ortho performs an x-ray, diagnoses osteoarthritis, and offers knee injection. Patient agrees and the injection is performed. Is a separate E/M justified? If so, what is the basis? Is it the fact that an x-ray was performed, which helps substantiate the MDM portion of an E/M?


An x-ray usually is above and beyond the normal injection, but the documentation must still support an E/M separate from the injection.


Question 15 from Abby R:

What if the provider prescribes an antibiotic, would it be appropriate to bill an e/m?


It depends - was the antibiotic prescribed for an illness related to the procedure? Or as a prophylactic measure to prevent infection after the minor procedure? This may require a provider query.


Question 16 from Piyali S:

A 12 yr old comes for a well visit and has mild scoliosis. Would that be modifier 25?


No, unless the scoliosis is worsening or there are other symptoms.


Question 17 from Debra S:

What about 96372 (Administration of Medication)? Should it be billed with an office visit, or only the medication? There would be additional dx for the office visit.


If the patient is only coming in for the injection, then no E/M would be billed.


Question 18 from Jennifer S:

If you have a patient with a history of head/neck cancer (no longer being actively treated), that is seen for follow-up surveillance by Otolargyngology, can you bill 31575 for Laryngoscopy along with an E/M?  What would allow the procedure to be separately identifiable?


Typically for these patients, they are also being asked about symptoms post-chemo and labs (and maybe a PET scan) are ordered. Look for anything outside of the patient just coming in for a laryngoscopy, and if there isn't anything, you may not have an E/M.

Again, if you weren’t able to catch the live presentation of Decoding the Mysteries of Modifier 25, you can watch it here on-demand at any time. And don’t be shy, ask any additional questions in the comment section below.

Questions or Comments?