Enhance Your Modifier 25 Know-How with 4 Tips

With increasing payers cracking down on modifier 25 claims, you should know exactly how and when to separately report an E/M service along with a procedure code to keep your coding on-track.

Coding and billing scenario is changing every single day and one needs to stay updated to ensure correct documentation, compliance and deserved pay. Here are a few pointers that will help you decide when to use modifier 25 correctly and improve your documentation skills.

Use Modifier 25 for E/M Codes

If your ob-gyn’s documentation supports that he performed an E/M service that was significant and separately identifiable from the work included in another service or procedure you should use modifier 25. You can use modifier 25 when coding an E/M service. If not the encounter qualifies for another modifier instead.

Before Adding 25 Identify E/M HEM

Along with the procedure that has been performed by the ob-gyn, one also needs to document the E/M service provided. One should use modifier 25 only with services that are “significant, separately identifiable” and “above and beyond the usual preoperative and postoperative care associated with the procedure.” On the contrary, only recording the patient’s history, obtaining consent, and explaining the procedure to the patient will only ensure normal protocol that is done before performing a procedure and will not be considered as a separate one.

If There is Same Dx Stop Omitting 25

A different diagnosis code is not required for proper modifier 25 use. In fact, the presence of different diagnosis codes attached to the E/M and the procedure does not necessarily support a separately reportable E/M service.

The documentation done by your ob-gyn should clearly establish that the visit’s purpose was not to perform the procedure. If in case you face denials on modifier 25 claim due to the use of same diagnosis code for the E/M and the procedure, you need to appeal assuming that the ob-gyn’s documentation is in support of reporting separate services.

Global Period Needs to be Checked

CCI manual states that while reporting modifier 25 in conjunction with minor surgical procedures one needs to be cautious. You should closely consider the specific clinical scenario and your documentation to verify that the E/M encounter can be reported separately. If any procedure has a global period of 000 or 010 days, it is considered to be minor surgical procedure. E/M services that are done on the same date of service as the minor surgical procedure are payable under the procedure. If a minor surgical procedure is performed it is included in the payment for the minor surgical procedure and cannot be reported as an E/M service separately.

By keeping these easy tips in mind, one can easily file reliable claims that are error-free and keep their coding and billing intact.

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