HIM Coding: Modifier 25 Usage

We can all learn the definition of Modifier 25,  “Significant, separately identifiable evaluation and management [E/M] service by the same physician or other qualified health care professional on the same day of the procedure or other service,” but do we really understand the meaning of it?

Let’s break down the meaning a little bit.

Significant, separately identifiable evaluation and management service. The E/M needs to stand alone from the procedure in that it must have the required three elements; history, examination, and medical decision making documented.

Example: An established patient presents with uterine bleeding requiring a hysteroscopy with an endometrial biopsy. The patient is also evaluated for a breast cyst. The breast evaluation consists of an expanded problem-focused history, physical exam, and medical decision making of low complexity.

In this case, only the E/M elements of the visit related to the breast cyst would be used to justify the correct level of service for the office visit. We would submit 99213-25 and 58558.

Example of inappropriate usage of Modifier 25: Patient came into the office for a troublesome lesion. The lesion is evaluated and removed at the visit. The surgical code includes the evaluation services necessary before the performance of the procedure, so no E/M code should be billed.

HIM Coding Modifier 25 Usage Blog Image

Do not forget to append the 25 to the E/M service when a procedure is performed and the E/M can stand alone. If you forget, the claim will be denied as incidental to the surgical procedure performed the same day. The insurance company will think it was a pre-operative service and deny it, as it would be included in the global package.

Commit to accurate coding. You don’t want to fraudulently up-code when adding modifier 25 to an E/M without significant, separately identifiable documentation, and treatment.


About The Author

Deborah Tysel

HIM Coding Manager for Healthcare Resource Group, Inc.


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