Appropriate Use of Modifier 25 in Cardiology

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Appropriate Use of Modifier 25 in Cardiology
Defining Modifier 25 Modifier 25 is a
significant, separately identifiable evaluation
and management service by the same physician or
other qualified health care professional on the
same day of the procedure or other service. It
may be necessary to indicate that on the day a
procedure or service identified by a CPT code was
performed, the patients condition required a
significant, separately identifiable E/M service
above and beyond the other service provided or
beyond the usual preoperative and postoperative
care associated with the procedure that was
performed. Note that, examples mentioned in this
article is just for reference purpose and you
must take the coding experts advice for
appropriate use of modifier 25 in cardiology
billing. A significant, separately identifiable
E/M service is defined or substantiated by
documentation that satisfies the relevant
criteria for the respective E/M service to be
reported. The E/M service may be prompted by the
symptom or condition for which the procedure
and/or service was provided. As such, different
diagnoses are not required for reporting the E/M
services on the same date. This circumstance may
be reported by adding Modifier 25 to the
appropriate level of E/M service. Note that
Modifier 25 is not used to report an E/M service
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Appropriate Use of Modifier 25 in Cardiology

• that resulted in a decision to perform surgery,
  you might use Modifier 57. For significant,
  separately identifiable non-E/M services on the
  same day, you might use Modifier 59.
• Coding Guidelines for Modifier 25
• Modifier 25 can be used for outpatient,
  inpatient, and ambulatory surgery centers
  hospital outpatient use.
• Modifier 25 can be used in other situations such
  as with critical care codes and emergency
  department visits.
• Do not use a 25 Modifier when billing for
  services performed during a postoperative period
  if related to the previous surgery.
• Do not append Modifier 25 if there is only an E/M
  service performed during the office visit.
• Do not use a Modifier 25 on any E/M on the day a
  Major (90 days global) procedure is being
  performed.
• Do not append Modifier 25 to an E/M service when
  a minimal procedure is performed on the same day
  unless the level of service can be supported as
  significant, separately identifiable. All
  procedures have an inherent E/M service
  included.
• Always link the modifier 25 (or any other
  modifier) to the E/M CPT code

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Appropriate Use of Modifier 25 in Cardiology

• It is not necessary to have two different
  diagnosis codes
• Need to document both the E/M and the procedure
• Modifier 25 may be appended to EM services
  reported with minor surgical procedures (global
  period of 000 or 010 days) or procedures not
  covered by global surgery rules (a global
  indicator of XXX). Since minor surgical
  procedures and XXX procedures include
  pre-procedure, intra-procedure, and
  post-procedure work inherent in the procedure,
  the provider should not report an EM service for
  this work. Furthermore, Medicare Global Surgery
  rules prevent the reporting of a separate EM
  service for the work associated with the decision
  to perform a minor surgical procedure, whether
  the patient is a new or established patient with
  the decision to perform surgery the same or the
  next day.
• Appropriate Use of Modifier 25 in Cardiology
• Example 1 (Using modifier 25) A patient visits
  the cardiologist for an appointment, complaining
  of occasional chest discomfort during exercise.
  The patient has a history of hypertension and
  high cholesterol. After the physician completes
  an office visit it is determined that the patient
  needs a cardiovascular stress test performed that
  day by the same physician.

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Appropriate Use of Modifier 25 in Cardiology
Accurate coding The physician or other qualified
healthcare provider codes an E/M visit (99202
99215), and the physician or other qualified
healthcare provider also codes for the
cardiovascular stress test (93015). Modifier 25
is added to the E/M visit to indicate a
separately identifiable E/M on the same day of a
procedure. The modifier 25 stops the bundling of
the E/M visit into the procedure. When reviewing
the physicians documentation, the insurance
carrier should be able to determine that both the
E/M and the procedure were medically necessary.
The documentation must support your offices
claim to the insurance carrier. Example 2 (Not
using modifier 25) When a patient is scheduled
to come into your office for a cardiovascular
stress test, and the physician also completes a
history and performs a limited examination
(specifically related to the stress test), your
office should only code for the cardiovascular
stress test (93015). Supporting
Documentation  When you submit a claim to the
insurance carrier coded with a 25 Modifier, you
are telling the carrier to pay you for both the
E/M visit and the minor procedure. Often, in the
past, claims with both an E/M and procedure have
been reviewed for accuracy. When you bill both
codes on the same day, will your documentation
support
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Appropriate Use of Modifier 25 in Cardiology
both codes? Will you have documented adequately
for the E/M separate from the procedure?
Typically, when these services have been audited,
payment was rescinded due to incorrect coding,
incomplete documentation, and/or lack of medical
necessity to support both codes billed on the
same day by the same physician. Modifier 25 is
one of the most commonly misused modifiers. Most
of the coders use modifier 25 to get
reimbursement for all performed procedures
without understanding the rules for bundling.
Note that the examples mentioned in this article
are just for reference purposes, and you must
take the coding experts advice for the
appropriate use of modifier 25 in cardiology
billing. MBC is a leading outsourcing medical
billing company providing complete revenue cycle
management services. If you need any assistance
in medical billing for your cardiology practice,
contact us at info_at_medicalbillersandcoders.com/ 88
8-357-3226
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Appropriate Use of Modifier 25 in Cardiology

• FAQs
• What is Modifier 25, and when is it used in
  cardiology billing?
• Modifier 25 indicates that a significant,
  separately identifiable evaluation and management
  (E/M) service was provided by the same physician
  or other qualified healthcare professional on the
  same day as another procedure or service in
  cardiology.
• When is it appropriate to use Modifier 25 in
  cardiology billing?
• Modifier 25 is appropriate when the E/M service
  provided is distinct and separate from the
  procedure or service being billed for, such as
  when a patient receives an E/M service during the
  same visit as a minor procedure or test.
• What documentation is necessary to support the
  use of Modifier 25 in cardiology billing?
• To use Modifier 25 correctly, the medical record
  must document the distinct nature of the E/M
  service provided, showing that it required
  additional work beyond the usual pre- and
  post-procedure care associated with the procedure
  or service performed.

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Appropriate Use of Modifier 25 in Cardiology

• What are the potential risks of incorrect use of
  Modifier 25 in cardiology billing?
• Incorrect use of Modifier 25 may result in claim
  denials, audits, and potential recoupment of
  payments, as payers scrutinize claims to ensure
  that the additional E/M service truly meets the
  criteria for being distinct and separate.
• How can medical billers and coders assist in
  ensuring the appropriate use of Modifier 25 in
  cardiology billing?
• Experienced medical billers and coders can review
  documentation thoroughly to ensure compliance
  with payer guidelines and documentation
  requirements. They can also educate and train
  healthcare providers on proper coding and
  documentation practices to optimize reimbursement.