OIG: 25 Modifier on their “Target List”

The OIG put modifier 25 on its “target list” after a report determined that related claims have substantial error rates and that the modifier has been inappropriately used on as many as thirty-five percent of submitted claims. Medicare contractors have been instructed to pay close attention to this issue.

Current Procedural Terminology defines modifier 25 as “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” It indicates that the patient’s condition requires an additional evaluation and management service beyond the usual preoperative care provided for the procedure or service. Modifier 25 should be appended to an exam when a separately identifiable service has been performed on the same day as a minor procedure. Minor procedures are defined by Medicare as those with zero (0) or ten (10) days of postoperative care.

Proper Use of Modifier 25

Example 1: A patient has a nosebleed. The physician performs packing of the nose in the office, which stops the bleeding. At the same visit, the physician then evaluates the patient for moderate hypertension that was not well controlled and adjusts the antihypertensive medications.

The 25 modifier may be reported with the appropriate level of E/M code in addition to the minor procedure.

Example 2: A patient visits the cardiologist for occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed that day by the same physician.

The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure.

Improper Use of Modifier 25

Example 1: A patient has a small skin cancer of the forearm removed in the physician’s office. This is a routine procedure and no other conditions are treated. The office visit is considered part of the surgery service and, therefore, not separately reimbursable.

The use of the 25 modifier is inappropriate. Only the procedure should be reported.

Example 2: A patient complained of right knee pain. Physician evaluated the knee, ordered a prescription of anti-inflammatory drug and scheduled a follow up visit; an arthrocentesis to be performed if no signs of improvement. Patient returned and arthrocentesis performed.

The use of the 25 modifier is inappropriate. The focus of the visit was related to the performance of the arthrocentesis.

Marilu Luna