Modifier Moment- 25

25 modifier use and mis-use

By CPT definition this modifier is used to unbundle a “ (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service)”

So how do you tell when the evaluation is significant or separately identifiable?

In some cases it’s quite easy as they may present with one issue say a cold and then request a mole be removed that’s been bothering them, obviously a cold and a mole are separate issues.

But sometimes it’s not so easy to identify and carve out a significant separate EM. Is it?

Remember all procedures with 0 or 10 global days have a certain amount of EM inclusive. CMS publishes info on the average pre and post op times for these services you can easily search. There is always a certain amount of pre and post op work inclusive to these procedures which can be confused with a medically necessary EM when it is really not. 

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2017-PFS-FR-Physician-Time.zip

So what makes a service separate?. A new patient? Not always! New patients can present just for a surgical service. Again pre and post op work is inherent.

If a patient evaluated by another provider and sent just for a procedure this does not necessarily support a 25 modifier. 

If again your patient with a cold needs to be sent to your derm provider to have the mole excised they would not necessarily need another evaluation. We need to consider if a truly significant, separately identifiable evaluation was performed. For me the easiest way is to look for a separate service is to check and carve out  the HPI,exam and the MDM that is above what is needed to perform the procedure. 

Ex1

HPI -sent for mole removal. Hx of mole for many years. No significant changes. Interferes w bra strap and is inflamed. No family history. Exam- lesion red and inflamed. MDM states plan- removal

As opposed to…

Ex2

HPI-sent for mole removal. Sister has a Hx of BCC. Would like to make sure this is benign lesion. Exam- detailed exam of skin all over body to check for suspicious lesions. MDM- given sun precautions, return every 6 months for skin check, proceed w lesion removal today.

See the difference? In the second example  we are addressing her skin status in general and making sure we follow her due to family history as well as performing a procedure but in the first case we are simply removing the offending mole. Ex 2 would support the use of 25

Comments and questions welcomed.