Using Modifier – 25 on an E/M Visit

 In recent years, there has been an increase in scrutiny regarding the use of modifier -25 to identify separate evaluation and management (E/M) services on the same day as another procedure. Insurers are now demanding documentation of such services both before and after payment, leading to a significant administrative burden for urology practices. The reason for this burden is unclear. It may be due to an actual overuse of such services, or it could be a strategic decision by insurers to eventually discourage practices from reporting E/M services on the same date of service as procedures, potentially resulting in long-term cost savings for the payers.

Regrettably, we have received reports that some groups have opted out of billing E/M services on the same date due to the high level of effort and expenses required to obtain proper reimbursement. Instead, these groups have chosen to provide free care or have patients return on another date for that aspect of their treatment. This is far from ideal as it places a significant burden on both patients and practices, resulting in delayed care and inconvenience for patients. The rules were established to ensure that services are reimbursed properly when billed correctly.

On the payer side, modifier -25 has been a target of focused review for several years. This modifier is defined as a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day as the procedure or other service. This scrutiny began after a report by the US Department of Health & Human Services Office of the Inspector General in 2005 revealed that modifier -25 was incorrectly reported in 35% of cases reviewed. Recently, payers have observed a lack of documentation or medical necessity in enough cases to warrant increasing their resources to review charts with modifier -25. Furthermore, it is probable that these reviews are being conducted using computer-assisted coding tools that utilize advanced recognition and processing techniques to expedite chart review, and coding personnel are also being added to enhance the number of charts that can be reviewed. Both of these investments by the payer must yield dividends in the short and long term.

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