Oct 2004 Table of Contents

GETTING PAID

Understanding When to Use Modifier -25



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This code can help you to get reimbursed for the extra work you do at certain visits.

Fam Pract Manag. 2004 Oct;11(9):21-22.

This content conforms to AAFP CME criteria. See FPM CME Quiz.

Many times a patient’s “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more. According to CPT, separate, significant physician evaluation and management (E/M) work that goes above and beyond the physician work normally associated with a preventive medicine service or a minor surgical procedure is additionally billable. The code that tells the insurer you should be paid for both services is modifier -25. Used correctly, it can generate extra revenue.

The key is recognizing when your extra work is “significant” and, therefore, additionally billable. CPT does not define “significant,” but asking yourself the following questions should lead you to the answer:

  • Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?

  • Could the complaint or problem stand alone as a billable service?

  • Is there a different diagnosis for this portion of the visit?

  • If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

If your answers to these questions are yes, then you should report the appropriate E/M code with modifier -25 attached as well as the preventive medicine service code or minor surgical procedure code. You can increase the likelihood that the insurer will pay for both services by organizing your note so that documentation for the problem-oriented E/M service is separate from documentation for the preventive service or procedure. You may even want to use headers or a phrase such as “A significant, separate E/M service was performed to evaluate … .”

Preventive medicine service with problem-oriented E/M service

The following examples might help clarify the difference between “significant” and “insignificant” services delivered in the context of a preventive medicine visit.

A 44-year-old established patient presents for her annual well-woman exam. A complete review of systems is obtained, and an interval past, family and social history is reviewed and updated. A neck-to-groin exam is performed, including a pelvic exam, and a Pap smear is taken. Counseling is given on diet and exercise. Appropriate labs are ordered.

The following situations would not be significant enough to warrant billing a separate E/M service:

  • The patient also complains of vaginal dryness, and her prescriptions for oral contraception and chronic allergy medication are renewed. This additional work would be considered part of the preventive service, and the prescription renewal would not be considered significant.

  • The patient also requests advice on hormone replacement therapy. She is anticipating menopause but is currently asymptomatic. This would not be considered significant because the patient is asymptomatic and preventive medicine services include counseling or guidance on issues common to the patient’s age group.

The following situations would be considered significant enough to warrant billing a separate E/M service:

  • The patient also complains of night sweats, hot flashes and lighter, irregular menses. After a discussion of treatment options, risks and benefits, a prescription for estrogen replacement is given. Because the patient is symptomatic and additional history is taken, along with medical decision making, this could be considered significant. The diagnosis code for menopause would be linked to the E/M code.

  • The patient also complains of fatigue, hair loss, feeling cold and lighter menses. On exam, mild hair thinning and areflexia are noted. The physician orders a complete blood count and thyroid stimulating hormone test with the intention of writing a prescription after reviewing the test results. Because symptoms are present and the physician documents extra work in all three E/M key components, this could be considered significant. Diagnosis codes for the symptoms would be linked to the E/M code.

  • The patient also complains of bilateral knee pain in the morning. Tenderness and swelling are found on exam. The patient is given a nonsteroidal anti-inflammatory drug prescription. The extra physician work that is documented for all three E/M key components makes this significant. The diagnosis code for knee pain would be linked to the E/M code.

  • The patient also states that home monitoring has shown fasting blood sugars of 120 mg/dL to 180 mg/dL and some random sugars over 300 mg/ dL. This is a significant problem that needs to be addressed, and extra physician work is done and documented for all three E/M key components. The diagnosis code for uncontrolled diabetes mellitus would be linked to the E/M code. The status of previously diagnosed stable conditions would be considered part of the preventive medicine service and not separately billable.

Minor surgical procedure with problem-oriented E/M service

The CPT codes for minor surgical procedures include pre-operative evaluation services such as assessing the site or problem, explaining the procedure and risks and benefits, and obtaining the patient’s consent. Also, the Centers for Medicare & Medicaid Services (CMS) has clarified that the initial evaluation is always included in the reimbursement for a minor surgical procedure and, therefore, is not separately billable.

However, when you perform an “Oh, by the way” E/M service at the same visit as a procedure and the E/M service requires physician work “above and beyond” the physician work usually associated with the procedure, the E/M service may be billed in addition to the procedure, with modifier -25 attached to signal to the payer that both services should be paid.

The following examples might help clarify what constitutes “significant” and “above and beyond.”

In the following situation, you should bill the minor surgical procedure code only:

  • The patient complains of a troublesome lesion, you evaluate the lesion and you remove it at that visit. The surgical code includes the evaluation services necessary before the performance of the procedure, so no E/M code should be billed.

For the following situations, bill the minor surgical procedure code in addition to the appropriate level E/M service:

  • At a follow-up visit for the patient’s stable hypertension and osteoarthritis, the patient also complains of a troublesome skin lesion that you remove at that same encounter. These services are separate and significant and not part of the preoperative services for the lesion removal. The code for the lesion removal would be linked to the appropriate lesion diagnosis code, and an E/M service linked to hypertension and osteoarthritis diagnosis codes should be submitted as well.

  • The patient presents with a head laceration, and you also examine the patient for neurological damage before repairing the laceration. It would be appropriate to bill both an E/M service and a laceration repair code because your work was above and beyond what is typically associated with a routine preoperative assessment of the laceration. Separate diagnoses would not be necessary.

The final analysis

Unfortunately, not all insurers will pay you for the separate E/M service even if you code in compliance with CPT rules. Be sure to have your staff appeal any denied or bundled claims. A review of your documentation by the insurer may actually result in payment for your work.

Dr. Felger teaches family medicine at St. Joseph’s Regional Medical Center in South Bend, Ind., and is chairman of the AAFP Commission on Health Care Services. Marie Felger is a medical coding consultant and certified professional coder. Both are coding instructors for the AAFP Course on Cash, Codes and Computers.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.


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