As coders we face many struggles, including determining when the use of modifier 25 is appropriate.
Modifier 25 was designed to indicate a significant, separately identifiable evaluation and management (EM) service, by the same physician/specialty on the day of a procedure with a global period of 0/10 days. What can be challenging is knowing when to apply the modifier correctly.
Since all EM services provided on the same day as a global procedure are bundled, CMS only allows separate EM payment if an exception applies. Qualifying exceptions include:
- The patient’s condition required a significant and separate EM service, above and beyond the usual pre and post-operative care associated with the procedure.
- In rare circumstances, a separate EM service is appropriate the day before a major surgery when the visit is unrelated to the decision for surgery.
- Modifier 24 is appropriate when a patient is seen, during a global period, for a separate issue.
- Modifier 57 is appropriate when a patient is seen, within the 24 hours before a major surgery, and the decision for surgery is made at that time.
- Documentation must clearly indicate that decision making.
Pro Tip 1: EM services are not bundled into procedures with XXX global days; therefore, modifier 25 is not applied.
Pro Tip 2: Modifier 25 should only be utilized when the criteria are met, not solely to ensure payment.
I have found that when you understand the rules of documentation it alleviates some of the challenge.
Director of Professional Fee Coding For Healthcare Resource Group, Inc.
Teresa Tate, CPC has over 16 years of coding, auditing and provider education experience. As the Director of Professional Fee Coding at HRG, Teresa and the HIM department are constantly coming up with solutions to the unique problems facing pro fee coding. Teresa, a true educator, is always willing to share her knowledge and experience to forward advancements in coding and the health services industry.