Here are three brief descriptions of when to properly use Modifier 25. Modifier 25 is the most common modifier used in an office based Medical practice and below are some easy to follow guidelines to reduce denials and improve collections. There are many great billing systems that have tables loaded which assist in using modifiers but you should never rely on technology (solely) when it comes to billing properly.
1. You have a different diagnosis for the E/M and the procedure. The two diagnoses may be related – such as when the diagnosis with the E/M is a sign or symptom and the diagnosis with the procedure more definitive. In this case, the E/M resulted in a decision to perform the procedure, either diagnostic or therapeutic.
2. The second condition is similar, except on doing the procedure, there is no second diagnosis. Medicare specifically states that there is no requirement forseparate and distinct diagnoses for the E/M with a 25 modifier and the procedure. So, for example, you may have a sign and symptom for the E/M. Then, the diagnostic minor procedure results in no definitive finding, so the sign or symptom would also be related to the minor procedure. The E/M still, as described above, was a decision to perform the minor procedure.
3. The “oh by the way” scenario, where the patient comes in for one problem (the E/M) and before the patient is finished with the physician, she states, “oh by the way, can you look at my …” If this request results in the performance of a minor procedure which is totally unrelated to the original reason for the visit, the diagnosis on the E/M and the minor procedure are totally unrelated.