Using Modifier -25

A podiatrist visits a nursing home to perform nail care and with each procedure, always bills a low-level nursing home service. His Medicare contractor wants to recoup all of the money for the E&M visits. Should he it fight it? Should he have billed the E&M services in the first place?

A gynecologist sees a patient for post-menopausal bleeding and decides to perform an endometrial biopsy at that visit. Can she bill for both? What if the patient returns the next day for the biopsy, should she bill a low-level E&M when performing the biopsy?

Where will physicians and staff find definitive answers to these questions? According to CPT, modifier -25 is used to indicate that an E&M service was performed on the same day as a procedure. It is defined as: "Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service." The diagnosis for both services may be the same, but the E&M service must be separate and distinct.

The Medicare Claims Processing Manual tells us that the evaluation and decision to perform the service is included in the payment for the service. Per Medicare Claims Processing Manual (100-04) Section 40.1 (B) Services not included in the global surgical package:

"These services may be paid for separately: The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure ..."

And the NCCI edits say: Per CCI (chapter 11, Letter R.):

"The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier -25."

Use modifier -25 only on E&M services, when a procedure with 0 or 10 global days is performed by the same physician on the same date of service. Use it only when the E&M service is separate and distinct. What does that mean? It means when it is medically necessary to evaluate the patient - not just the site of the procedure - prior to performing the service. Evaluating the site of the procedure and making the decision to perform the procedure is included in the payment for the procedure itself.

You would be likely to perform and document a separate E&M in these cases:

• New onset post-menopausal bleeding, when an endometrial biopsy is performed after the evaluation;

• Patient presents with anemia and bleeding, and a surgeon decides to perform an endoscopy; and

• Initial evaluation for a non-healing wound, and a procedure on the wound itself.

You would be less likely to report both an E&M and a procedure in these clinical situations:

• For a planned, repeat procedure such as wound care;

• For a patient who presents for the procedure, i.e., "Patient presents today for a LEEP after an abnormal pap smear";

• For minor procedures such as lesion destruction; and

• For planned, routine foot care provided to nursing home patients.

It may be difficult for a clinician or coder to decide if the visit meets the criteria of separate and distinct. Look at the note, and highlight the portion of the note that references the E&M service. Is there any reference to the E&M service, or is it all related to the procedure? If the key components of an E&M service are documented, do they show that the physician evaluation happened on that day? Or do they simply repeat a past history: "I saw this patient last week with a non-healing wound, debrided it, and asked him to return for another evaluation and debridement." Restating the history and plan developed at a previous visit does not count as a separate E&M service.

Betsy Nicoletti is the founder of Codapedia.com and the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at betsy.nicoletti@gmail.com.