Modifier 25
Key Takeaways
Modifiers 25 and 57 continue to be a common source of coding confusion, despite no recent guideline changes.
An Evaluation and Management service is only separately billable when it is significant and unrelated to the procedure performed.
Routine pre-procedure assessment is included in the global surgical package and should not be billed separately.
Clear, standalone documentation is critical to support appropriate modifier use and reduce audit risk.
Listening to a presentation on Modifiers and then a Question and Answer session at the AMA symposium yesterday it became clear that modifiers 25 and 57 continue to present challenges for coders. There were no changes to these modifiers or guidelines for their use.
Modifier 25 is defined in CPT as a “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”. A surgeon once indignantly exclaimed he always had the right to evaluate a patient prior to a surgery, during a training session. He was absolutely correct as this constitutes good medical practice / patient care. The real question is, when is this service separately billable?
If a patient is seen in the office and scheduled to come back in a week for a small procedure e.g., because they need conscious sedation this initial service is billable without issue and requires no modification. The day of the procedure the provider visits the patient, takes/reviews vital signs and the area undergoing surgery to make the determination the patient remains appropriately healthy for the planned procedure. This work is considered included in the pre-procedure work for the surgical procedure and should not be billed separately with a modifier 25. Conversely if a patient comes in for the scheduled surgical procedure and has developed a new problem that requires management prior to performance of the procedure this would be separately billed with a modifier 25 and mapped to the appropriate ICD 10 CM code on the claim. Coders should take care to individually map diagnosis codes to the CPT code they support on the billing form.
Surgeons in some specialties frequently get referrals for small procedures on patients that are new to their practice. They will perform an Evaluation and Management (E/M) service to gain a baseline picture of the level of health, need for the procedure that was ordered and discuss treatment options/plans, and gain consent. Some litmus tests to determine when to bill these encounters are as follows:
1) Did the patient have conditions unrelated to the planned procedure that required evaluation and management (e.g., treatment) above and beyond the work needed to assess the patient for the procedure? If yes then code the E/M service with a 25 modifier.
a. An example is the patient with multiple health problems that require extensive review and management of an unrelated health problem that could impact the surgical outcome. e.g., a medication that might impact healing or coagulation.
2) Was the crux of the E/M service aimed at evaluating the patient for the problem they were scheduled have the procedure for? Would the E/M service have been needed if there was no procedure scheduled? If the crux of the E/M service performed on the day of a procedure is procedure centric and would not otherwise have been performed then the E/M note is not billed as it is considered part of the pre-procedure work for the procedure.
Some third party payers will allow an E/M (with a modifier 25) visit on the same day as a procedure for small procedures in the ER where the majority of the visits are new to the provider. Individual payer policies that are in writing can be used to bill E/M with a modifier 25 on the same day as a small procedure.
Most often an E/M visit on the same day as a major procedure is to make the decision to do the surgery and in this case modifier 57 is more appropriate. If the patient is seen for something unrelated to the reason for the surgery such as a post operative allergic reaction to a medication on the same day as surgery then this is separately billable with a modifier 25. Managing post operative complications on the same day as surgery such as bleeding are not billed unless the patient requires a return to the operating room for Medicare beneficiaries.
CPT does indicate postoperative care as part of the global surgical package is relegated to “normal post operative recovery.” The clinical record would need to identify how, why and to what extent post operative care is outside of the normal when coding care in the post operative / same day setting for non-governmental payers.
At the end of the Question and Answer session 2 presenters indicted they asked the question, “Can the E/M note stand on it’s own for reasons unrelated to the procedure?”
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