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Appropriate Use of Modifier 25 in Cardiology

Defining Modifier 25

Modifier 25 is defined as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. Note that, examples mentioned in this article is just for reference purpose and you must take the coding expert’s advice for appropriate use of modifier 25 in cardiology billing.

A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting the E/M services on the same date. This circumstance may be reported by adding Modifier 25 to the appropriate level of E/M service. Note that Modifier 25 is not used to report an E/M service that resulted in a decision to perform surgery, you might use Modifier 57. For significant, separately identifiable non-E/M services on the same day, you might use Modifier 59.

Coding Guidelines for Modifier 25

  • Modifier 25 can be used for outpatient, inpatient, and ambulatory surgery centers hospital outpatient use.
  • Modifier 25 can be used in other situations such as with critical care codes and emergency department visits.
  • Do not use a 25 Modifier when billing for services performed during a postoperative period if related to the previous surgery.
  • Do not append Modifier 25 if there is only an E/M service performed during the office visit (no procedure done).
  • Do not use a Modifier 25 on any E/M on the day a ‘Major’ (90 days global) procedure is being performed.
  • Do not append Modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have an ‘inherent’ E/M service included.
  • Always link the modifier 25 (or any other modifier) to the E/M CPT code
  • It is not necessary to have two different diagnosis codes
  • Need to document both the E/M and the procedure
  • Modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of 000 or 010 days) or procedures not covered by global surgery rules (a global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient with the decision to perform surgery the same or the next day.

Appropriate Use of Modifier 25 in Cardiology

Example 1 (Using modifier 25): A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed that day by the same physician.

Accurate coding: The physician or other qualified healthcare provider codes an E/M visit (99202 – 99215) and the physician or other qualified healthcare provider also codes for the cardiovascular stress test (93015). Modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure. The modifier 25 stops the bundling of the E/M visit into the procedure. When reviewing the physician’s documentation, the insurance carrier should be able to determine that both the E/M and the procedure were medically necessary. The documentation must support the claim that your office sends to the insurance carrier.

Example 2 (Not using modifier 25): When a patient is scheduled to come into your office for a cardiovascular stress test and the physician also completes a history and performs a limited examination (specifically related to the stress test) your office should only code for the cardiovascular stress test (93015).

Supporting Documentation 

When you submit a claim to the insurance carrier that is coded with a 25 Modifier, you are telling the carrier to pay you for both the E/M visit and the minor procedure. Often in the past claims with both an E/M and procedure have been reviewed for accuracy. When you bill both codes on the same day will your documentation support both codes? Will you have documented adequately for the E/M separate from the procedure? Typically, when these services have been audited payment was rescinded due to incorrect coding, incomplete documentation, and/or lack of medical necessity to support both codes billed on the same day by the same physician.

Modifier 25 is one of the most commonly misused modifiers. Most of the coders use modifier 25 with the goal of getting reimbursement for all performed procedures without understanding the rules for bundling. Note that, examples mentioned in this article is just for reference purpose and you must take the coding expert’s advice for appropriate use of modifier 25 in cardiology billing. MedicalBillersandCoders (MBC) is a leading outsourcing medical billing company providing complete revenue cycle management services. If you need any assistance in medical billing for your cardiology practice, contact us at info@medicalbillersandcoders.com/ 888-357-3226

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