Keeping up with modifier 25 rules can be intimidating, so let’s add a little fun by seeing if you can unearth the answers to these questions at the locations provided. Ready, set, go!
1. Is This a Separate E/M?
You may have the descriptor memorized for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).
Even if you don’t (the descriptor has gotten lengthier over the years, after all), you should know the basic concept: you use the modifier to identify a significant, separately identifiable E/M beyond the usual pre- and post-operative care for a procedure.
So here’s your first challenge: Suppose a physician sees a new patient who has presented with a head trauma. The physician determines the patient requires sutures and does an allergy and immunization status check before beginning. Based on that information, should you report a separate E/M service using modifier 25 in addition to the suture service code?
Hint: Start your search in our SuperCoder blog post about modifier 25: Straight From the Source: Use Modifier 25 the Right Way With CCI Manual Tips.
2. Append Modifier 25 or 57?
One of the tricky areas for modifier 25 use is knowing when to apply that modifier instead of modifier 57 (Decision for surgery).
That leads us to the next question: If you perform a procedure with a 0- or 10-day global period, and documentation supports reporting an E/M code as well, should you append modifier 25 or 57 for Medicare?
Hint: You can track down the answer in this Part B Insider article: RACs Zero in on Modifier 57 Usage. (You can read the article even if you’re not a Part B Insider or Part B Coder subscriber because the article was included in our free SuperCoder Bolt e-newsletter.)
3. Does Modifier 25 Have a Role for 90-Day Global?
You just looked into modifier 25 with a procedure that has a 0- or 10-day global period. But can you use modifier 25 when there’s a procedure with a 90-day global involved?
Here’s the question: You’re reporting to the Part B J5 MAC. Can you append modifier 25 to the code for a separately identifiable E/M service performed the day before a major surgery when the E/M is not the decision for surgery?
Hint: Checking payer policies about modifier 25 is important to be sure you have complete information to work with for your specific claim. That’s why this final question requires you to end your scavenger hunt with the WPS GHA Modifier 25 Fact Sheet. If the site asks you to choose a jurisdiction, remember that the sample scenario is for Part B J5.
Not Into Hunting Down Answers? We Got You
If you couldn’t find an answer or just prefer to have all your information in one place, look below for answers to each of the questions in our hunt.
Answer 1: Both the National Correct Coding Initiative (CCI) manual, chapter 1.D, and the Medicare Claims Processing Manual (MCPM), chapter 12, section 40.1.C, say you should not report an E/M code to represent services provided in the encounter described in question 1. But if the physician performed a full neurological exam that was medically necessary because of the head trauma, reporting a separate E/M code may be appropriate, depending on the documentation.
Answer 2: For Medicare, the general rule is to use modifier 57 only for an E/M that represents the decision for surgery for a major procedure, meaning one with a 90-day global period, so that leaves you with modifier 25 for this question. But before you append modifier 25 to an E/M on the same date as a procedure with a 0- or 10-day global service, make sure it meets all the requirements. You can review the rules in the CCI manual and MCPM sections referenced in Answer 1 above.
Answer 3: The answer is yes. The Fact Sheet states, “Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.” But be sure the service you report is not bundled into or with any other services according to payer and coding guidelines, of course.
What About You?
How did you do on the modifier 25 scavenger hunt? Do you find that payers are changing the rules about using modifier 25? Are the lines between 25 and 57 getting blurred, depending on the payer?