Get the Rightful Reimbursement for Separately Identifiable E/M Services Using Modifier 25

You may invite an audit if you report a separate evaluation & management every time your dermatologist performs a procedure. Learn how to get your rightful pay for separately identifiable E/M services using modifier 25 with the help of these three guidelines.


First, see to it that your dermatologist carried out a separate service. Use modifier 25 when your dermatologist's documentation supports that he carried out an E/M service that was significant and separately identifiable from the work included in another service or procedure.


Take a look at the documentation and cross out anything that's directly related to the procedure carried out. Then take a look at the remaining documentation to figure out if it is indeed significant, separately identifiable and medically necessary.


According to CPT's Appendix A, a significant and separately identifiable service "is defined or substantiated by documentation that satisfies the relevant criteria for the respective evaluation & management service to be reported."


Remember: You can only consider reporting modifier 25 when coding an evaluation & management service. If the procedures you are reporting do not fall under evaluation & management services, it is possible the encounter qualifies for another modifier instead.


Second, you should not confuse modifiers 25 and 57. The difference between these two modifiers is a common point of confusion since both involve your dermatologist carrying out a procedure and distinct evaluation & management service for the same patient on the same day. The fastest distinction is that you'd use 25 for a distinct E/M with a minor procedure, and 57 for a distinct E/M with a major follow-up procedure.


How it functions: You should only use modifier 25 with procedures that have a 0- or 10-day global period. Medicare defines these procedures as minor. In comparison, you will use modifier 57 for procedures with a 90-day global period. Remember that some payers are now requesting 57 on 10-day globals.


Stop omitting 25 because of same Dx. Proper modifier 25 use does not require a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the E/M and procedure doesn't necessarily support a separately reportable E/M service. The guidelines changed years ago that you don't need to have a different diagnosis to use modifier 25. Nevertheless it still seems easier to get paid if the diagnoses are different.


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