Resolved E/M and imaging on same day

[BriannaC_80549]

Does a modifier 25 need to be on the E/M when imaging (CT/ PET) done on the same day??

 

[Darcy]

Does a modifier 25 need to be on the E/M when imaging (CT/ PET) done on the same day??

Depends upon a few factors;
Who are you coding/billing for? Facility or physician?
Was there a separate, significant E/M performed?

 

[Lori]

Modifier 25 is appended with E&M codes, only when the same physician performs a separate procedure on the same day. Mostly the X rays, CT without contrast, Labs, IV infusion, injection are the common procedures done with E&M codes.

All medical procedures have an “inherent” E/M component that assesses the medical necessity of the procedure and the patient’s overall health. Consider the E/M to be part of the service and not separately billable if the office visit briefly touches on the reason for which the procedure is being performed. However, work which is “integral to that procedure” does not support a separately billable E/M service. For modifier 25 to be assigned, the patient’s condition must require the provider to go above and beyond the usual care associated with the procedure.

Why is the patient being seen?​

• We’re the physician’s or other qualified health care professional’s evaluation and management of the problem significant and beyond the normal preoperative and postoperative work?
  • Yes, an E/M may be billed with modifier 25
  • No, it is not appropriate to bill with modifier 25
• Does the complaint or problem stand alone as a billable service?
  • Yes, an E/M may be billed with modifier 25
  • No, it is not appropriate to bill with modifier 25
• Did the physician perform and document the key components of an E/M service for the complaint or problem?
  • Yes, an E/M may be billed with modifier 25
  • No, it is not appropriate to bill with modifier 25
• Is there a different diagnosis for a significant portion of the visit? Or if the diagnoses are the same, was extra work above and beyond the usual preoperative and postoperative work associated with the procedure code?
  • Yes, an E/M may be billed with modifier 25
  • No, it is not appropriate to bill with modifier 25
• Are there signs, symptoms, and/or conditions the physician or the other qualified health care professional must address before deciding to perform a procedure or service?
  • Yes, based on the documentation, an E/M service might be medically necessary with modifier 25
• Was the procedure or service scheduled before the patient encounter?
  • Yes, it is not medically necessary to bill for an E/M
• Is there more than one diagnosis present that is being addressed and/or affecting the treatment and outcome?
  • Yes, bill the procedure code and the E/M with modifier 25
  • No, it is not appropriate to bill with modifier 25

Modifier 25: When to Use, and When NOT to | Healthcare Data Management

Many healthcare providers (and sometimes even coders and medical billing companies) incorrectly believe that anytime an E&M (evaluation and management code, 99XXX series) is billed with another service, the modifier 25 needs to be appended to the E&M. The rationale behind Modifier 25 is that it...

healthcarebiller.com

5 Essential Tips for Using E/M Modifier 25 | Experity

In this month’s “3 Things to Know About RCM,” we review E/M code modifier 25 and COVID-19 reimbursement updates for urgent care

www.experityhealth.com

Significant and Separately Identifiable Service
Modifier 25 indicates that on the day of a procedure, the patient’s condition required a significant and separately identifiable evaluation and management (E/M) service above and beyond the norm. Two significant aspects to note are that the service must be “significant” and “separately identifiable”.

• Significant: For modifier 25 to order to support an E/M code, the work must be significant. As a recent Medical Economics report clarifies, this means that a problem that requires considerable workup or treatment, or a problem that, if not addressed at the current visit, would need the patient to return for another visit to address it. A minor problem or concern would not support the billing of an E/M service in addition to a procedure.
• Separately identifiable: To use modifier 25, the documentation should show that the E/M service is above and beyond the usual pre-/post-operative services integral to the procedure. While it is not required to document the E/M visit separately from the pre-/post-op work, the documentation should clearly indicate the work that was performed to support a separate E/M visit.

Learn About Appropriate Use of Modifier 25 for E/M service codes

Knowing the rules is crucial for physicians to overcome confusion about submitting E/M service codes with modifier 25 appended.

www.outsourcestrategies.com

Please see this thread for more on modifiers:

Resource - CPT Modifiers

CCO Video Modifiers Made Easy: FREE CCO TOOL: https://www.cco.us/cpt-modifier-decision-grid-tool/ 22- Increased Procedural Services 23- Unusual Anesthesia 24- Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative...

www.cco.community

Please see this thread for more on E/M:

Resolved - E/M Updates

What’s Changing for E/M Codes 99201-99215 in 2021? https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx#:~:text=The%202021%20guidelines%20also%20take,the%20risk%20of%20complications%20and%2F

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