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Tip Sheet: Proper Use of Modifier 25 

A review of top claim reason codes indicate a steady reoccurrence of claims being returned to provider (RTP) for reason code W7021, when there was a medical visit on same day as a type 'T' or 'S' procedure without modifier 25 on the claim.

Definition

Modifier 25 indicates a “significant, separately identifiable evaluation & management (E&M) service by the same physician on the same day of the procedure or other therapeutic service.”

Reminder on Modifier 25 Use

Both services rendered must be significant, separate and distinct. In general, Medicare considers E&M services provided on the same day of a procedure to be included in the procedure, and as such, will not make separate payment.  The exception to this rule is when the E&M documentation supports a significant, separately identifiable service above and beyond what the physician would normally provide, and when the visit can stand alone as a medically necessary billable service. In all cases where modifier 25 is appropriately used, the provider must take care to ensure documentation is present in the medical record to fully support both the visit and the procedure. 

Appropriate Use

  • Scenario 1: Patient presents for scheduled nail debridement. Patient also complains of severe heel pain for several weeks.  Following nail debridement, physician evaluates patient’s heel pain and determines patient may be developing plantar fasciitis. Physician recommends over the counter pain medication, stretching, and shoes with good arch support and schedules patient for a follow up visit in four weeks.
    • Rationale: Physician evaluated a distinct and separate issue apart from the debridement therefore, a separate E&M with modifier 25 would be appropriate in addition to the debridement.
  • Scenario 2: Patient presents with a head laceration following a fall at home.  Physician also examines the patient for neurological damage before repairing the laceration.
    • Rationale: It would be appropriate to bill both an E&M service and a laceration repair code because the physicians work was above and beyond what is typically associated with a routine preoperative assessment of the laceration.  Separate diagnoses would not be necessary.

Inappropriate Use

  • Scenario 1: Patient presents for scheduled nail debridement. Patient has no other complaints or issues. Debridement completed without incident.  Patient scheduled for follow up visit in four weeks.
    • Rationale: Physician performed the nail debridement, no additional complaints addressed.  There was no significant, separately identifiable E&M performed therefore it would only be appropriate to report the debridement service.
  • Scenario 2: Patient has a small skin lesion of the forearm removed. This is a routine procedure and no other conditions are treated.
    • Rationale: Physician removed skin lesion. No additional complaints addressed. The use of modifier 25 is inappropriate. Only the procedure should be reported.

Provider Action

When billing an E&M service along with a procedure, your documentation must clearly demonstrate:

  • Purpose of the E&M service was to evaluate a specific complaint
  • Complaint or problem addressed can stand alone as a billable service
  • Extra work was performed above and beyond the typical work associated with the procedure code
  • Purpose of the visit was other than evaluating and/or obtaining information needed to perform the procedure/service
  • Both the medically necessary E&M service and the procedure are appropriately and sufficiently documented by the physician in the patient’s medical record to support the claim for these services

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Tip Sheet: Proper Use of Modifier 25
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