When can modifier –25 be used with an E/M code?

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We were told that we could not use modifier –25 on an evaluation and management (E/M) code unless we have a new diagnosis. Is this true?

No, this is not true for Medicare, nor is it true from a CPT standpoint. However, some payers will deny an E/M code with a modifier –25 if both the E/M code and the procedure or service reported on the same date have the same diagnosis code. Of course, some payers will categorically deny any number of services that are correctly reported. We would encourage you to report correctly and, as always, appeal wrong denials, making sure that your documentation supports the services billed.

The instructions from CMS to the carriers are very clear in the following excerpt from the “Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners 30.6.6 – Payment for Evaluation and Management Services Provided During Global Period of Surgery”:

“A/B MACs (B) pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier –25 is added to the E/M code on the claim.”

The instructions from the CPT manual are also fairly straightforward and are included in the full definition of modifier –25 included below (emphasis added in italics).

“Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.”

Remember that even though a new diagnosis is not required, the definition of the modifier and the rules surrounding the use of the modifier –25 require that the E/M service is significant and separately identifiable. This means that the documentation for the visit must clearly reflect E/M services provided on the same date cannot be services that are normally provided in conjunction with the service.

As an example, a patient is scheduled for a cystoscopy. The global service package would include making sure the patient is fit to have the service provided including any history, physical examination, and medical decision-making related to deciding to proceed with the service.

What if the cystoscopy revealed a bladder tumor of unspecified behavior? If documented, the time spent discussing the treatment options and recommendations could be reported separately under an E/M code with modifier –25 even though both the cystoscopy and E/M would be reported with the same Dx code, as treatment of the finding is not a part of the diagnostic cystoscopy.

In a seminar that you taught recently, you said that writing a prescription, providing a sample of a prescription drug, or deciding to refill a prescription should be billed as a level 4 E/M code. Now, my E/M curve has almost all level 4s; is this going to trigger an audit?

There are several issues that we will address in this question. First, we would like to apologize for a misunderstanding that your question represents. When we teach E/M coding guidelines, we attempt to carefully communicate accurate E/M coding according to the current published guidelines. Although “prescription drug management” referenced in your question above relating to prescription drugs dispensed (writing a prescription, giving a sample of a prescription drug, or renewing a prescription) to treat presenting problems represents a level 4 in terms of the risk element of medical decision-making, it cannot be considered as the sole determining factor in code level selection.

When we teach E/M coding, you may recall that we talk about proper documentation for history, physical examination, and medical decision-making. We also talk about counseling and time where appropriate. Every part of E/M coding counts and is dependent upon both circumstance (place of service, patient status, etc.) and medical necessity. Space does not allow us to address all of these issues in this article.

For this question, we will address scoring of medical decision-making (MDM). It sounds like you are focused on billing based on E/M key components and must have proper documentation for the other components of history and/or physical examination. For MDM, remember that the level of this component is based on two of three elements. The three elements are number of diagnoses or problems, amount of data, and amount of risk. Two of these three must meet or exceed the level selected for the MDM level of the visit.

As an example, a patient who presents with prostate cancer that is being treated at this point with LHRH and monitoring of PSA for the visit would have a level 3 number of diagnosis or problem (one problem with active management), a level 2 amount of data (PSA review), and a level 4 risk (prescription drug management) with decision to administer and dosing for the LHRH. Based on MDM considered in total, the overall level of the MDM for the visit is level 3, even though the amount of risk based on prescription drug management would qualify for a level 4.

Remember to document well and take a look at the visit as a whole. We would also recommend an updated education session through a respected organization such as Physician Reimbursement Services or the AUA.