Q. What is the definition of modifier 25?

A. Current Procedural Terminology defines modifier 25 as “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” It indicates that the patient’s condition required an additional evaluation and management  service beyond the usual preoperative care provided for the procedure or service. 

Q. What types of procedures require the use of modifier 25?

A. Modifier 25 should be appended to an exam (992xx or 920xx) or consultation (9924x) when a separately identifiable service has been performed on the same day as a minor procedure. Minor procedures are defined by Medicare as those with zero (0) or ten (10) days of postoperative care.  Examples include foreign body removal (65222), punctal occlusion with plugs (68761), epilation for correction of trichiasis (67820) and the laser and injection procedures listed below. 

Q. If the physician makes the decision to perform a minor procedure on the same day as the office visit, does modifier 25 apply to that visit?

A. Not always. Unlike major surgeries (those with a 90-day postop period), the office visit is often included with a minor procedure and not separately billable. CPT states that, “this modifier is not used to report an E/M service that resulted in a decision to perform surgery.”  In addition, the Medicare Claims Processing Manual, Chapter 12, §40.2A4 states, “where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.” 

Q. If the patient has two different diagnoses being addressed, is it appropriate to bill the office visit with modifier 25?

A. Yes. If the patient does have more than one problem being addressed at the visit, it is appropriate to use different diagnoses on the claim. However, it is not required that two different diagnoses exist. The CPT definition of modifier 25 specifically states, “different diagnoses are not required for reporting of the E/M services on the same date.”

Q. If only one diagnosis exists, how do we determine when to bill the visit as well as the procedure?

A. The CPT definition says that a separately identifiable service must be provided. If the physician has to cope with more than one occurrence of the same problem but do so in different ways, then the visit and the procedure are billable. For example, your patient presents with two chalazions: a large one on the right eye, and a small one on the left eye. You incise and drain the larger one, and treat the small one with medications and warm compresses.  Both the exam and the minor procedure carry the same diagnosis (i.e., 373.2). The exam would be filed with modifier 25 and the procedure would be modified with RT to designate right eye.

Q. When is it inappropriate to use modifier 25 to file separately for the exam and the procedure?

A. If the only purpose of the exam is preoperative care, or to determine the need to proceed with the procedure, then a claim for an office visit with modifier 25 would not be appropriate. For example, your patient was last seen six weeks ago and received her third intravitreal injection to her left eye. Examination today will determine whether a fourth injection is needed now or can be postponed. OCT of the left eye demonstrates progressive exudative AMD. You proceed with the injection to the left eye based on these findings. Your examination of the fellow eye is unremarkable and noncontributory.  The decision for minor surgery does not, in itself, support the use of modifier 25..

Why are payers interested in modifier 25 usage? 

A. There are several reasons why payers, especially Medicare contractors, are interested in physician claims using modifier 25. The Office of Inspector (OIG) 2011 General Work Plan included “Evaluation and Management Services During Global Surgery Periods” as a target for scrutiny. Its 2012 Work Plan continues to include this issue. OIG expects to determine if the number of E/M services provided during the global surgery period has changed since the global surgery concept was developed in 1992. The 2012 OIG Work Plan also includes a new investigation of E/M claims with modifiers during the global surgery period that resulted in payment, citing that prior OIG work found inappropriate payments. It should be noted that in 2005, the OIG published a report indicating that 35 percent of claims filed in 2002 with modifier 25 did not meet the requirements. They instructed Medicare contractors to pay attention to this issue. Minimal reviews occurred immediately following the OIG’s request. The 2011 and 2012 OIG Work Plans seem to have resurrected the effort. 

Q. Are the Recovery Audit Contractors (RAC) interested in this issue?

A. Yes, all four RAC organizations list on their websites that evaluation and management services during the global surgery periods for both major and minor procedures are under review.

Q. How frequently do ophthalmologists use modifier 25? 

A. Data from the Centers for Medicare & Medicaid Services indicates that ophthalmologists utilized modifier 25 on 9 percent of office visits submitted in 2009 (the most recent data available at this time). It is one of the most frequently used modifiers in ophthalmology and its use continues to grow.

Q. Is there a particular reason for the increased utilization of modifier 25?

A. Yes. Some surgical procedures have been redefined from major procedures to minor procedures in the past few years. For example, laser trabeculoplasty (65855) is a minor procedure; it was previously a major procedure. As of January 1, 2011, laser peripheral iridotomy (66761) also became a minor procedure. Both procedures have 10 postop days. Intravitreal injections (67028) have grown to be the second most frequently performed surgical service in ophthalmology. This procedure is also a minor procedure with zero postop days. When physicians file for an office visit on the day of these procedures, modifier 25 is required.  

Ms. McCune is vice pres­ident of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.