Billers and coders for ENT practices nationwide consider Modifier 25 a blessing or a curse. On one hand, it is conveniently used to bill for separate evaluation and management services performed on the same day as a procedure. On the other hand, it is confusing and can cause denials if not used correctly. Michelle Netoskie, Fuel Medical’s Billing, Coding & Compliance Manager, noticed that many of our members have experienced severe issues with third-party payers due to incorrect use of Modifier 25. This Ask Fuel First section answers the question: How do I know when to use Modifier 25?
What Is Modifier 25?
Modifier 25 is a medical code that bills for separate evaluation and management (E/M) services provided on the same day as a procedure. It can be used with various health care specialties and is a standard code for billing different insurance companies, including Medicare. By adding Modifier 25 to your billing, you’re indicating that you’ve provided a service that is separate and identifiable beyond the primary procedure and requires reimbursement separate from the primary code.
Using Modifier 25 can be confusing because the biller and coder must determine if the E/M meets the requirement of being separate and identifiable from the procedure.
A Scenario
To understand how ENT practices can bill insurance companies using Modifier 25, consider the following scenario:
A patient has an appointment with an ENT practice hoping to get help with a feeling of fullness in their ears. At the beginning of the appointment, the patient tells the ENT about the fullness they feel, which the ENT diagnoses as excessive earwax after examination. The ENT performs irrigation to remove the earwax. Then, the patient says they’ve been having a sore throat occasionally. The ENT uses a scope to examine the patient to determine that there’s nothing wrong. Because the ENT doesn’t see any polyps, they tell the patient they have reflux and prescribe medication to help alleviate the symptoms.
During this visit, two services were provided: one service concerning earwax diagnosis and removal and another service to diagnose reflux. When detailing this visit to the paying insurance company, the primary purpose of the visit was to diagnose earwax using CPT code 99214, which resulted in earwax removal that was part of the office visit because it did not rise to level of impacted cerumen CPT Code 69210. Then, Modifier 25 would be added to CPT code 99214 along with the code 31575 for using a laryngoscope.
Getting Into Trouble
The main purpose of using Modifier 25 is to bill for separate E/M services, which is necessary when a patient also has a procedure on the same day. If not coded correctly, practices could get into trouble using Modifier 25. Some ways that billers misuse this modifier include the following:
- Lack of proper documentation: To justify using Modifier 25, the documentation must clearly explain which separate services were provided and how they differ. This takes the guesswork out of the equation for insurance companies reviewing your claims.
- Different days of service: Modifier 25 can only be used for services provided on the same day by the same provider. Using it on claims for different days will result in an automatic denial.
- Pre- and post-operative services in a surgical global package: Modifier 25 cannot be used for services provided before and after an operative service as these aren’t considered significant, separate E/M services.
- Confusion with other modifiers: If the guidelines for using Modifier 25 are regularly confused with other modifiers, insurance companies may consider doing an audit, looking back at all modifiers used in a specific time period.
- Complexity of care: Finding a qualified biller and coder can be challenging, so some practices resort to hiring less qualified employees. If these employees don’t understand the procedures they’re coding for or how procedures relate to each other, they may inadvertently use the wrong codes or modifiers.
Rampant misuse of Modifier 25 can trigger an audit, so it’s important that your billers and coders are well-versed in the use of modifiers.
The Easy Road Isn’t the Best
Some practices might bill the scenario above as a single visit. This is certainly the safer option in terms of avoiding potential audits, but it’s not the right decision for the business. Incorrect billing results in a loss of potential income even though the patient benefited from the provider’s time and expertise. Conversely, using Modifier 25 too aggressively to bill for every service being provided might result in errors. Remember, Modifier 25 can only be used with separate E/M services on the same day as a procedure. Be sure your billers are using the correct codes and modifiers to avoid future audits.
Tips to Avoid Confusion Using Modifier 25
Staying current on ENT-specific coding is the best way to avoid confusion when using Modifier 25 and any other modifier. Refer to guidelines from organizations like the AMA and CMS.
Clear communication between billers and providers can prevent problems. This includes thoroughly reviewing providers’ notes and asking for clarification when necessary. If a provider isn’t documenting patient visits appropriately, the biller should feel comfortable enough to discuss improvement ideas. When the provider knows why the biller has critiqued their notes and the possible consequences, they’ll be more likely to follow their suggestions.
Finally, seek guidance if you aren’t sure about a specific code or modifier. Being proactive is always better than reactive. It’s harder to recover from an audit than to prevent one from occurring. If you have questions about billing and coding, don’t hesitate to reach out to your Fuel Medical regional team for support.
