Forum - Questions & Answers

Apr 14th, 2015 - TerryC 39 

Modifier 25

My employer is telling me to use a modifier 25 on every E/M visit if we do anything else at all. Whether it be a procedure,injection,UA dip, etc. I don't feel this is correct. However they say there getting denials from insurance companies when there is no modifier??? Does anyone have a thought. Thanks
I don't want those "red flags" to start flying.

Apr 14th, 2015 - petunia 195 

re: Modifier 25

I would suggest a Google search of information on the 25 modifier. I believe there are great articles that also provide scenarios of appropriate modifier usage. I am sure a lot of visits may qualify but to add a 25 modifier to every visit is asking for trouble. CMS and other government carriers are good advisors.

Apr 14th, 2015 - Codapedia Editor 1,399 

re: Modifier 25

Petunia has good advice here. Thank you.

I think we all overuse modifier 25 because select payers require it. In order to get a well child visit and an immunization paid, we are required by some payers to add modifier 25 to the well child visit. Billing an injection and medication with an E/M? Some payers require modifier 25. So, we add it for all payers, to make it easier.

Is it absolutely correct from a coding perspective?

Maybe not.

Does it result in our being paid more than we should, based on the work done? Not when added *unnecessarily* to an E/M service done with a U/A. So, from a compliance perspective, there isn't an error. We didn't collect more money than we were entitled to collect.

The compliance risk is when adding an E/M service and modifier 25 to a procedure or other service when ONLY the procedure should have been reported.

I object to payers requiring modifier 25 when it isn't required by coding rules, but if they require it, (and it doesn't result in payments that are incorrect) add it.

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