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Procedure Coding: When To Use The Modifiers

Modifiers are valuable coding tools that explain to payers the specific work that was done by a physician during treatment of a patient. They’re important for representing the medical decision-making (MDM) a physician must demonstrate in order to bill, and be paid for, all the services they render.

DEFINING MODIFIER 25

Modifier 25 is a particularly meaningful coding tool for physicians who bill for evaluation and management (E/M) services. CPT guidelines define the 25 modifier as “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”

Modifier 25 reports that the physician performed an exam which qualified as significantly separate from any other services rendered that day. But what qualifies that exam as ‘significantly separate’ from the rest?

CLINICAL SCENARIOS

The following is an example of when to use modifier 25 to appropriately code for a provider’s services:

Example:

An oral physician examines an established patient during a regularly scheduled routine check and performs a full intra oral and extra oral examination During the patient’s exam, a new suspicious lesion is discovered. The physician determines this should be tested. He performs an oral DNA and CBCT.

In this scenario, the E/M would qualify as a separately identifiable service (updating patient history from the past year exam of moderate-high complexity)that required further diagnostic tests. The correct and appropriate reporting for this visit would be to add modifier 25 to the E/M and code the completed services as follows: 99213-25,
JUSTIFYING USE OF MODIFIER 25

As with all matters of provider service billing, understanding the necessity of justification of services performed is mandatory. In a word (or maybe three): document, document, document. Especially with modifier 25, clear, detailed physician documentation is key to supporting the MDM involved during the treatment rendered.

The provider must demonstrate their thought process in the required documentation, as it will serve a critical role; without a proper medical record, payers may continue to render determinations of incorrect claim denials or underpayments. With proper supporting documentation, even if a payer is incorrectly denying services, the physician’s billing staff will have a leg to stand on when filing claims reconsiderations.

SUMMARY

Understanding the correct and appropriate use of modifier 25 will be key to filing correct claims, which will then result in correct payment. Not only does the 25 modifier allow us to code physician services to the highest level of specificity possible, but it ensures the physician is paid accordingly for those services. However, this doesn’t mean coding and reimbursement is all dependent upon modifier 25 alone; physicians are responsible for sufficiently documenting the need for E/M services separate from the procedure/s subsequently performed.

Physicians and their coding and billing staff will need to work as a team in order to create the clearest and accurate E/M claims, fully supported with proper medical documentation.

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