Coding and Billing

Modifier 25: When to Use & When NOT to Use it in Coding & Billing

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

Sept. 2, 2020

Modifiers in coding and billing should be used judiciously. The Office of the Inspector General has specifically cited overuse of Modifier 25. Here is how to use this modifier exactly as it was intended.

Modifier 25 is one of the most commonly misused modifiers.

The definition of Modifier 25 is: “Modifier 25 is defined as a 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.”

Let’s break this definition into its key phrases.
• 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

From the definition we can see there are two codes in consideration here: an examination code and a procedure code. Let’s see how these definition phrases impact our coding. A couple of examples will help.

In the following two cases, the patient is seen by the same physician (or optometrist) on the same day.

EXAMPLE 1
The patient came into your office complaining of pain in their right eye. Upon examination, you discover a corneal foreign body. Nothing else is discovered. Can you bill for both the examination and for the corneal foreign body removal? No. The reason is because the examination is related to the corneal foreign body discovery and it is not a significant, separately identifiable E/M service. In this case, you can only bill for the procedure (the corneal foreign body removal).

EXAMPLE 2
Let’s consider a similar, but different, example. The patient came into your office complaining of pain in their right eye and a red left eye. Upon examination, you discover a corneal foreign body in the right eye and also bacterial conjunctivitis in the left eye. Can you bill for both the examination and for the corneal foreign body removal? Now, the answer is yes. The reason is because the examination is related to the discovery of the bacterial conjunctivitis and is, indeed, a significant, separately identifiable E/M service from the procedure. In this case, you would code for the E/M examination with the modifier 25 and also code for the corneal foreign body removal procedure.

It is important to also keep in mind the following:
• The reason for the visit and the procedure must be both medically necessary and documented as medically necessary.

o For the examination, the reason for the visit for the example given above would be identified as “red eye” (FYI, “left” would be under History of Present Illness).

o If the procedure is a surgical procedure, a good statement to use in your records is: The presence of ___ triggered the medical necessity for ordering ___ from ___ on ___.

For the procedure, using the above example above to fill in the blanks:
The presence of the corneal foreign body triggered the medical necessity for ordering corneal foreign body removal from Dr. Wright on today at 3:00 p.m.

• Document the examination using SOAP notes.
o Subjective
o Objective
o Assessment
o Plan

• Document non-surgical procedures using this outline:
o Clinical Findings
What did you do, what did you find, were the results reliable

o Comparative Data
Change in condition, comparison to previous procedures, has the condition gotten worse, stayed stable or improved

o Clinical Management
Record what effect the test/procedure is having on your clinical management for the patient such as change in medication, referral, consultation request, order additional testing

• Document surgical procedures using OPERATORY notes.
o Medical condition
o Previous treatment attempted
o Informed consent
o Procedure description
o Outcome statement
o Discharge instructions

Know the rules and follow code definitions exactly in order to code appropriately.

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