Know About the Perfect Use of Modifier 25 in Physician Billing

A modifier helps explain that a service or procedure was done differently due to a special situation, but the actual code or definition hasn't changed. Modifiers are important for following the payment rules set by others. One of the vital modifiers that you need to use with your physician billing services is modifier 25, thus requiring you to know about it clearly.

Know what modifier 25 is:

You need to use modifier 25 when performing a separate and completely different Evaluation and Management Service on the same day as another procedure. Unfortunately, most novice physician billing teams still find it confusing to use this particular modifier, thus requiring you to have a sound understanding of the appropriate use of modifier 25.

Know when you need to use modifier 25 in your physician billing:

You need to use modifier 25 when a patient comes for a scheduled procedure but you also examine the patient for a new or separate issue during the same visit. In this case, Modifier 25 can be added. It shows that the extra check-up or evaluation was separate from the first service.

Make sure this extra service is completely different from the care that you provide before or after the procedure. It must also be properly written down in the patient's medical record as you cannot bill it if it is not documented.

It's also important to know that both services can be related to the same problem. They don't need to have different diagnoses. For example, if a patient comes in with a sore throat and the provider removes something from the throat and also checks for infection, Modifier 25 can be used. The two services are connected but still separate.

However, don't use Modifier 25 if the only reason for the visit was to decide on surgery. For that, use Modifier 57 instead as it clearly shows that the visit calls fot the necessary surgery. And if the provider does a completely different service, not related to an exam or evaluation, use Modifier 59. That shows two separate procedures were done.

Using modifiers correctly helps avoid billing mistakes and supports proper payment.

However, there are some vital considerations that you must know when using modifier 25 and the following are the considerations:

Major considerations of using modifier 25:

• When reporting an E/M service along with a procedure on the same day, the E/M work must go beyond the usual preoperative and postoperative care that comes with the procedure. Providers must understand what is already included in the surgical package, as those parts (consent discussion, reviewing imaging or lab findings related to the procedures, follow-up planning) cannot be billed separately. You can find the list of included services from the CPT codebook.

  These include patient history, physical exam, care before and on the day of surgery, and immediate post-op tasks like notes, family updates, orders, recovery checks, and follow-up. Standard pre- and post-procedure care also covers reviewing history, examining the issue, explaining the diagnosis, discussing options, getting consent, giving instructions, and planning next steps. Make sure you are not reporting these routine tasks separately with an E/M code.

• There are times when you need to use more than one E/M service and then, you must use modifier 25 with an accurate E/M code. For example, if a significant problem is found during a preventive medicine visit, and extra work is needed, use modifier 25. Make sure that you are not using modifier 25 when the problem is minor and doesn't need any separate medical decision-making.

Unfortunately, many physicians are still unable to maintain an efficient billing team that can understand all the nuances of physician billing services, especially the proper use of modifier 25. However, you can still avoid all the complexities of your billing mechanism. Wondering how? You can simply hire a professional physician billing company, as they know what it takes to handle modifier 25 and all the nuances of billing, thus ensuring a seamless RCM process and amplified revenue for your practice.