Hot Topic of the Month:
Proper Use of Modifier 25

For many of us, the proper use of modifiers means the provider can effectively collect for services which otherwise would be rejected. The proper use of modifier and their understanding is critical to maximize the reimbursement for your doctor.

A modifier indicates to the reporting facility that a service or specific procedure has changed without actually affecting the applicable CPT code. The Medicare Outpatient Prospective Payment System represents the most significant change in the method of hospital payment since its inception. Appropriate payment is primarily determined by the accuracy and completeness of the CPT and HCPCS codes and modifiers on the claim. The adjudication process for an outpatient claim includes extensive edits and payment rules, which can result in loss of revenue and cash flow delays should a claim not be coded appropriately.

Modifiers may be used in outpatient hospital settings to indicate that:

• A service or procedure has been increased or reduced
• Only part of the intended service or procedure could be performed
• An evaluation and management service was performed on the same date as a procedure
• TO delineate a circumstance wherein a patient receives multiple evaluation and management services performed by the same or different physician in multiple hospital outpatient settings
• An adjunctive service was performed
• A bilateral procedure was performed
• A service or procedure was planned prospectively at the same time of the original procedure
• Unusual events occurred, e.g. Procedure terminated due to alteration in patient’s status

To append modifier 25 appropriately to an E/M code, the service provided must meet the definition of “significant, separately identifiable E/M service”, as identified by the CPT code set.

Modifier -25 was approved for hospital outpatient use on June 5, 2000.

Source: American Academy of Professional Coders, The Coding Edge, March, 2004