Revisiting modifier 25

January 16th, 2019 / By Rebecca Caux-Harry

Since the Final Rule for 2019 averted the threat of reduced payment for professional services concerning the -25 modifier, I thought revisiting this troublesome modifier would be a good idea. The official descriptor, copied from the CPT manual is this: 

“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. 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 (see Evaluation and Management Services Guidelines for instructions on determining level of E/M 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 diagnoses are not required for reporting of 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: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.”

This is one of the longer descriptors for modifiers in the CPT manual and this modifier has had almost constant scrutiny by the OIG. CMS has long believed that coders have been using this modifier in error. When I first started coding, urban legend held that we needed different diagnosis codes when appending the -25 modifier to an E/M services provided on the same date as a procedure with a 0-day global period.  In fact, this widely held belief was the reason that language was added to the descriptor stating that different diagnoses weren’t necessary. I believe the instructions for using this modifier are quite clear; unfortunately, many E/M services are coded by providers with varying degrees of information about when to use this modifier. Thus, the scrutiny by the OIG.

The Final Rule removed the proposed reduced payment for services reported with the -25 modifier due to strong stakeholder opposition. CMS proposed using multiple procedure payment reduction (MPPR) logic to reduce payment by 50 percent for the lesser of the two services, believing that efficiencies are gained when the provider performs two services during the same encounter. The benefit to CMS is estimated at approximately 6.7 million RVUs. The impact to the provider community depends on the frequency of this occurrence within each practice. While I agree, some efficiencies are gained in this scenario, I disagree that a 50 percent reduction in payment is warranted.  Additionally, there may be impact to the patient. The provider may elect to have the patient make a follow-up appointment to provide the service, avoiding the reduction. We avoided this reduction for CY2019, however, I suspect that like MPPR, we’ll see this proposal again, maybe with a different proposed reduction. 

How do we avoid it? We can do a few things proactively. Get with your providers in order to give them as much information as possible about this modifier. Provide excellent education on documentation requirements so that audited services are defensible. We have to prove as a collective that we all understand the proper use of this modifier. I don’t know if this will impact CMS’ decision to revisit this issue, but at least we’ll know we’re submitting well supported codes on compliant claims for services provided. 

Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.