Modifier –25 Revisited

American Academy of Ophthalmology Web Site: www.aao.org
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Savvy Coder: Coding & Reimbursement

By Sue Vicchrilli, COT, OCS, Academy Coding Executive, and George A. Williams, MD, Member of Academy Health Policy Committee

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Are you using modifier –25 appropriately? Payers have noticed an upward trend in its use and have responded by conducting a rash of audits—and that makes today an opportune time to double-check that you’re using it correctly.

Seven Questions

Q. How is modifier –25 defined?

A. A significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

Q. What is the definition of “the procedure or other service”?

A. A minor procedure, which is defined as a procedure with a global surgical period of zero or 10 days.

Q. Modifier –25’s description states “evaluation and management service.” Does this mean you’re prohibited from appending it to an Eye code?

A. No. It may be appended to Eye codes (92XXX) as well as E&M codes (99XXX).

Q. Should modifier –25 be appended to the exam when a test (such as visual field, optic nerve scan, fundus photography, etc.) is done on the same day?

A. No. Modifier –25 is not needed in such a case. Inappropriate use may trigger an audit unnecessarily.

Q. Should modifier –25 be appended to a minor procedure code?

A. Never! It is always appended to the appropriate level of exam code.

Q. Isn’t modifier –25 associated with minor procedures in the same way that modifier –57 is associated with an initial decision for surgery?

A. No. Modifier –57 is appended to the appropriate level of exam when the decision to perform a major surgery (one with a 90-day global period) is made. Modifier –25 indicates that the exam is “separately identifiable.”

Q. What documentation do auditors seek when modifier –25 is used?

A. Each surgical code, whether minor or major, is divided into three parts: 1) Preoperative assessment, 2) intraoperative and 3) postoperative. Auditors are instructed to extrapolate from the exam any reference to preop assessment and postoperative care and then determine if what is left is indeed “separately identifiable.”

Three Examples: Would You Use Modifier –25?

Example 1. Chief complaint: Patient presents with neovascular AMD in the left eye status post-Lucentis injection one month ago. Reports vision is improved in left eye but now has decreased vision in the right eye with distortion.

Exam shows new neovascular AMD in the right eye. Left eye has active neovascular AMD. OCT and fluorescein angiography confirm neovascular AMD in right eye.

Plan: Patient is treated with Lucentis in right eye. Return for Lucentis in left eye in three days. (In coding this case, would it be appropriate to use modifier –25?)

Example 2. Chief complaint: Patient presents for follow-up of:

Reassessment of wet AMD in right eye. Patient says she is doing well, no changes in vision, both distance and near.
Floaters in both eyes. Decreasing in frequency since last visit.
Dry eyes improved with increased use of artificial tears and concentration on improved blinking during time on the computer.

Plan: Marked improvement on OCT. Recommend intravitreal injection today. Continue with dry eye regimen, adding ointment at night as needed. Continue to monitor floaters. (In coding this case, would it be appropriate to use modifier –25?)

Example 3. Chief complaint: Patient here for #3 injection in right eye. Reports vision not great but stable.

Plan: Recommend intravitreal injection today. Follow-up in two months. OCT next visit. (In coding this case, would it be appropriate to use modifier –25?)

Answers: Modifier –25 would be appropriate in examples 1 and 2, but not in example 3.

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