How to use modifier 25 correctly: Seven tips to promote revenue integrity in your medical practice
Was the evaluation and management (E/M) service significant and separately identifiable from another minor procedure or service on the same day? That’s the central question physicians must ask themselves when deciding whether to add modifier 25 to an E/M code. Adding it brings more revenue to the medical practice, however, adding it incorrectly means your medical practice could face costly claim denials, recoupments, and fines. Not sure how to use modifier 25 correctly? Read this article to learn more about rules for using modifier 25.
Modifier 25: An OIG target
Modifier 25 has been in the Office of Inspector General (OIG) spotlight for quite some time and the OIG continues to pursue cases against healthcare providers that use it inappropriately. Most recently, the OIG cited dermatology as an area of focus. Why? In 2019, the OIG found that approximately 56% of dermatologists’ claims with an E/M service also included minor surgical procedures such as lesion removals, destructions, and biopsies on the same day. The OIG is taking a closer look at these types of claims to determine whether they complied with Medicare requirements.
Even though the OIG specifically calls out dermatology in its 2022 Work Plan, all specialties are at risk for improper use of modifier 25. For example, on November 30, 2021, the OIG published an enforcement action against a urologist for inappropriately using modifier 25 to separately report an E/M service on the same day as a testosterone injection. On June 10, 2022, the OIG published an enforcement action against a podiatrist for submitting claims using modifier 25 to obtain Medicare and TRICARE reimbursement to which the practice was not entitled. Similarly, the OIG has cited wound care providers, chiropractors, and others for improper use of modifier 25. Knowing when to add modifier 25 is critical for all provider types.
Tips to promote revenue integrity
If you think your medical practice could be at risk for noncompliance, here are seven tips to help ensure revenue integrity.
1. Ask yourself: Did my work go above and beyond what’s usually included in the minor procedure? For example, did the minor procedure resolve the patient’s presenting problem? If it did, you’re probably not able to bill a separate E/M service using modifier 25. If it didn’t, a separate E/M service may be warranted.
2. Separate the documentation for the E/M service from the documentation for the minor procedure. The whole point of modifier 25 is to help physicians get paid for services that go above and beyond the usual pre- and postoperative work. Ensure that documentation for the E/M service clearly stands on its own, describes why the extra work was necessary, and details what specific work was performed.
3. Submit additional documentation, when required. Some payers always require more information before paying a claim that includes modifier 25. Know which payers follow this protocol and ensure you give them what they need in a timely manner.
4. Be cognizant of additional payer-specific nuances. For example, some payers never permit billing a level two E/M service on the same day as a minor procedure. Other payers never permit modifier 25 at all. Consider creating a spreadsheet of payer policies regarding the use of modifier 25 so you know when you can and can’t use it. Also pay attention to carrier outreach and education on the use of modifier 25. Many carriers publish modifier 25 fact sheets. Here’s one example from Novitas Solutions.
5. Look for specialty-specific modifier 25 examples. Many medical associations provide modifier 25 articles and other resources. Here’s one from the American College of Cardiology, another from the American Academy of Family Physicians, and a third from the American Optometric Association. These resources can help you understand how to use modifier 25 correctly by providing modifier 25 examples that resonate with the services and procedures you typically provide.
6. Perform an audit. Start with an internal audit of a few claims. If you notice errors, consider expanding the scope or even working with an external auditor to understand patterns and trends. The goal is to tackle the problem—not continue to ignore it and hope it goes away.
7. Know what to do if you think you have a problem. If you see errors with modifier 25, consider using the OIG’s self-disclosure protocol. By self-disclosing errors, including the incorrect use of modifier 25, you may be able to avoid the costs and disruptions associated with a government-directed investigation and civil or administrative litigation.
Conclusion
Modifier 25 affords providers the valuable opportunity to gain additional revenue. However, with that power also comes responsibility. Providers must understand how and when to use modifier 25 so they don’t become the target of an audit or investigation. Learn how edgeMED’s Revenue Cycle Management service can help you prevent billing errors, reduce claim denials and increase your revenue. Plus, visit the Healthy Snacks Blog for more expert insights, best practices and industry trends.
