Ever get confused on when you should use modifier 25? Do you get denials saying the procedure is included with another service on your claim? Let's discuss what modifier 25 is defined as and when it should be used.
Modifier 25 is used on Evaluation and Management (E/M) codes to distinguish significant, separately identifiable E/M service by the same health care professional on the same day as a procedure or other service. Meaning, a patient comes in to the office for a visit and a procedure, that was not previously planned, is performed.
Let's look at a few examples:
35 year-old established male patient presents to the office for right knee pain. CC,HPI,ROS and Exam are entered and support E/M code 99213. While the doctor is examining the patient's knee he asks if he could get his flu shot while in the office. Since the knee pain is significant and separate from the flu shot, modifier 25 should be used. Your claim would look something like this:
99213 - 25 (E/M Service)
90471 (Vaccine admin)
90674 (Vaccine)
50 year-old established female patient presents to the office for a routine follow up on her hypertension and diabetes. Medication, blood pressure and blood sugars are reviewed, and a change is made to her diabetic medication. While in the office, she mentions her right ear has been bothering her and asks that it be looked at. During examination, physician finds that her ear is impacted with cerumen which they decide to remove via irrigation. Documentation supports E/M level 99214 and code 69209 is billed for the ear irrigation. Since the patient's HTN and DM were discussed and were significant and separate from her ear pain, modifier 25 should be used. Here is what your claim would look like:
99214 - 25
69209
The E/M service has to be significant and separately identifiable in order to be billed with modifier 25 in addition to the procedure. The exam or work done cannot be considered part of 'routine preoperative' services.
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