Modifier 25 under Fire: Are You Using It Correctly?

The Centers for Medicare & Medicaid Services (CMS) has again identified the potential overuse and misuse of Current Procedural Terminology (CPT®) code modifier 25. In the recently published proposed rule for the calendar year (CY) 2017 Medicare Physician Fee Schedule, CMS indicates that its CY 2015 Medicare claims review shows that 19 percent of the codes that describe 0-day global services were billed more than 50 percent of the time, with an evaluation and management (E/M) service with modifier 25 appended. CMS maintains that the routine billing of separate E/M services may indicate a possible problem with the valuation of the procedure codes, which are intended to include all of the routine care associated with the procedure. The agency has identified a number of high-volume codes to review for possible duplication of resources and overvaluation.1 This issue has been raised on multiple occasions since 2005, when the Office of the Inspector General (OIG) published an analysis showing that 35 percent of Medicare claims for modifier 25 did not meet Medicare program requirements.2 Since then, CMS and private payors have increased their scrutiny of codes reported with this modifier, sometimes resulting in significant repayment to Medicare. For example, earlier this year, the U.S. Attorney’s Office for the Northern District of Georgia reached a settlement with a dermatology practice to pay $1.9 million to settle claims that they violated the False Claims Act by billing Medicare for E/M services that were prohibited under Medicare rules.3 To understand why modifier 25 is under this type of scrutiny, surgeons need to understand how its use is defined. Simply put, modifier 25 is appended to an E/M code when a procedure and a separate and significant E/M service is performed by the same physician during the same session or on the same date.4 For example, an established patient comes to your office with a suspicious lesion and, based on your assessment, you decide to excise it. You wonder if you can report an E/M code with modifier 25 appended, as well as the minor procedure code for excising the lesion. The definition of what is “separate and significant” is at the heart of whether both an E/M *All specific references to CPT (Current Procedural Terminology) codes and descriptions are © 2015 American Medical Association. All rights reserved.