October 2000 Bulletin

HCFA eyes use of -25 modifier with E/M

Adequate documentation needed to support service ‘beyond the usual’ or ‘separately identifiable’

By Annette Grady

With the use of -25 modifier under scrutiny by the Office of the Inspector General of the Health Care Financing Administration, it is now more important than ever to document properly.

Modifier -25 is defined by the American Medical Association as a modifier that is used with Evaluation and Management codes to signal a significant, separately identifiable E/M the same physician performed on the same day as a procedure.

Surgical procedure CPT codes do include certain evaluation services prior to the surgical procedure. This may include determination of site, seriousness of patient’s condition, explaining risk, options and the procedure itself. However, there are circumstances that may be significant and identifiable, and these are not included with the basic assessment.

Further, the physician may need to indicate the patient’s medical condition required above and beyond the usual 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 diagnosis is not required.

Correct use of the -25 modifier will need adequate documentation and also documentation support of the level of service (E/M code). The -25 modifier may be used with the following E/M codes:

To assure success in using the -25 modifier, document those extra circumstances that made the service "beyond the usual" or "separately identifiable". Although two separate diagnoses are no longer required it is helpful when it comes to reimbursement. Diagnosis is the most important element to improve the reimbursement process and is an excellent step towards total quality management. Recent studies have found that proper use of ICD-9 coding can significantly reduce reimbursement problems and improve quality of workflow in the medical practice. It is important to document all circumstances of the patient’s condition. This will enable your office note to support the "beyond the usual" and "separately identifiable" and also, demonstrate the medical necessity of the services. When providing an E/M service with a procedure on the same day (joint injections, minor office procedures, cast applications), attach the -25 modifier to the E/M service and documentation of the following.

  1. The reason for the encounter, clearly stated.
  2. Appropriate history and physical examination.
  3. Review of any labs, X-rays and other ancillary services.
  4. The reason for and results of diagnostic tests.
  5. Relevant health risk factors. (Patient is taking diuretics, steroids, etc.)
  6. The patient’s progress, including response to treatment, change in treatment and patient noncompliance
  7. Assessment plan of care: treatments and medications (specify frequency and dosage); any referrals and consults; any patient/family education; specific instructions for follow-up; and discharge summary and instructions.

(It is usually not necessary to use modifier -25 if you are seeing a new patient for the first time. Therefore, new patient codes, [e.g., 99201—99205], where there is an associated procedure does not require the use of this modifier. HCFA realizes a new history and examination are necessary and an immediate decision must be made before performing a surgical procedure in a patient never seen before.)

Today, HCFA, Blue Cross, and other third party payers are making increasing demands for justification of treatment. Therefore, it is essential to be as specific as possible to avoid denied claims. Diagnoses help identify the medical necessity of services provided by describing the circumstances of the patient’s condition, which will demonstrate medical necessity.

Annette Grady, CPC, CPC-H, is a board member of the American Academy of Professional Coders; and coding and reimbursement coordinator for a 10-physician multiorthopaedic specialty practice.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.


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