Modifier 25 and 57: Know These Modifier Basics

Here are three guidelines to unlock the secrets to rightful physician reimbursement for separately identifiable E/M services using modifier 25.


1) First, see to it that your dermatologist carried out a separate service. You should append modifier 25 when your dermatologist's documentation supports that he carried out an evaluation & management service that was significant and separately identifiable from the work included in another service or procedure.


Heed this advice: You should look at the documentation and cross out anything that's directly related to the procedure carried out. Then look at the remaining documentation to figure out if it is significant, separately identifiable and medically necessary.


Guidance: 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 and management service to be reported.


Bear in mind: You can think about reporting modifier 25 only while reporting an evaluation and management service. If the procedures you are reporting do not fall under evaluation and management services, it is likely the encounter qualifies for another modifier in its place.


2) You should not confuse modifiers 25 and 57. The difference between 25 and modifier 57 is a common point of confusion as both involve your dermatologist carrying out a procedure and distinct evaluation and management service for the same patient on the same day.


The fastest distinction is that you'd use modifier 25 for a distinct evaluation and management with a minor procedure, and 57 for a distinct evaluation and management with a major follow-up procedure:


This is how it functions: You should use modifier 25 only with procedures that have a 0- or 10-day global period. These kinds of procedures are what Medicare defines as minor. In comparison, you will use modifier 57 for procedures with a 90-day global period. However remember that some payers are now requesting 57 on 10-day globals; as such check with your individual payers.


3. You should stop omitting 25 because of same Dx. Right modifier 25 use doesn't require a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the evaluation and management and the 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. However it still seems to be easier to get paid if the diagnoses are different.


For more on this and for your rightful physician reimbursement, sign up for a one-stop medical coding guide like Supercoder. Onboard such a site, you can have access to a Physician Coder's Powerpack among a host of other tools to assist you in your coding.