Introduction
Modifier 25 is a critical part of the Medicare program, but it can be difficult to understand and use correctly. In this post, I’ll explain what Modifier 25 does, why it’s needed, and how to use it properly.
If a patient comes in for a preventive visit and the physician also performs a minor procedure, you do not need to use modifier 25 at all.
If a patient comes in for a preventive visit and the physician also performs a minor procedure, you do not need to use modifier 25 at all. In this case, Medicare will pay for the E/M service and the separately payable procedure (for example, ordering a test) as long as both are performed on the same day.
Modifier 25 is also used when there are two or more E/M services provided during the same day by different physicians who see patients at different times during their office hours. This includes doctors who provide care on an urgent basis in an emergency department or urgent care facility that is not part of their practice site where they normally see patients (see section II).
You’ll need to report modifier 25 for two or more E/M visits on the same day – even if one of them is a prolonged services code – if the visits are provided by different physicians.
You’ll need to report modifier 25 for two or more E/M visits on the same day – even if one of them is a prolonged services code – if the visits are provided by different physicians. This can occur when you have an established relationship with multiple specialists and you schedule several appointments in a single day, or if your frequent medical complaints require additional treatment from different physicians.
For example:
● Dr. Jones schedules two 10-minute E/M visits for John Smith on Tuesday afternoon at 3 p.m., so she can see him before her vacation leave begins that night at midnight. She provides service during both of these encounters regardless of being paid separately for each visit. As such, she reports modifier 25 on both claims because they were provided by different physicians in the same patient visit date range (as indicated by Medicare’s billable period dates).
Make sure you’re using the correct E/M code for your documentation.
Make sure you’re using the correct E/M code for your documentation. If you’re not sure what code to use, ask your billing company. If the code is correct, but the modifier isn’t, you’ll need to resubmit the claim.
If you’re submitting an electronic claim for a patient who has Medicare Part B and gets back a rejection, check the Remark Code box to see what’s wrong.
If you’re submitting an electronic claim for a patient who has Medicare Part B and gets back a rejection, check the Remark Code box in the error message to see what’s wrong. If you don’t check the Remark Code box, you won’t know what’s wrong. Resubmission will most likely be required if you don’t check this box.
Another common reason for denial is that you didn’t attach an operative report to the claim.
The second most common reason for denial is that you didn’t attach an operative report to the claim. If you don’t attach an operative report, any claim for minor procedures will be denied. The operative report is required by Medicare as part of a valid request for payment. In contrast, major procedures do not require an operative report since there are no CPT codes that require this documentation.
If you don’t attach the appropriate documentation at all, the provider must request it from his or her patient before billing Medicare again and getting paid for that service. If something goes wrong with your medical procedure (i.e., if there’s some kind of complication), then this process can take several weeks longer than it would have otherwise because providers have to wait on patients to send in their records before submitting claims again—and every time something goes wrong with a procedure, physicians are losing money due to administrative delays caused by lack of proper documentation over what went right versus wrong during treatment sessions!
Modifier 59 is typically not acceptable instead of modifier 25.
In this case, you cannot claim two or more separate E/M services on the same day with modifier 59. If you did so and Medicare audited your claims, they would deny them because modifier 59 is only applicable to single E/M services provided on the same day as an outpatient procedure.
Modifier 25 is typically not acceptable instead of modifier 59. Modifier 25 is used to denote that a service was performed by multiple physicians (i.e., two or more physicians), whereas modifier 59 only allows for one physician performing an outpatient procedure or CPT code 99XXX-XX9X9X99ZX9X99ZX99ZX99ZWZZZZZZZZWZ in a given day.
Denials can be avoided when the rules are followed correctly.
You’ll avoid denials and get paid faster when you’re using modifier 25 correctly.
Modifier 25 is a code that serves to indicate that a procedure or service was performed at the same time as another procedure or service. It can be applied only if there is a clear relationship between the two procedures, such as performing both surgeries on an injured limb and replacing damaged tissue with a graft. The following are some examples of how modifier 25 should not be used:
Conclusion
If you are denied, the most common reason is that the physician did not follow all of the rules correctly. This can affect a lot of different codes and scenarios, so it’s important to be familiar with each one. The key takeaway here is to make sure your documentation is accurate and complete before submitting claims for reimbursement.
