Episode 123: Decoding Modifier 25: Navigating Documentation and Billing in Healthcare

Coffee with Coker is a healthcare business podcast from the Coker group that focuses on solutions to help healthcare organizations effectively navigate the changing healthcare industry landscape. And here we are again. Hey, Erika. Hi, Jaci.

Well, last time we met for a podcast, we left everyone with a huge cliffhanger. We said the podcast this time would be the modifier 25 and we've pulled ourselves together and we're ready to do it. Yeah. As much as we can pull ourselves together on the topic of modifier 25.

We did it. So modifier 25 in my mind is a very opinionated modifier. And as auditors, we talk about this a lot. We have to be very careful not to voice our opinions in our audit work.

We can make comments, but we have to keep away from opinions. So I think the best place to start and Erika, you've done an excellent job. I think we should start with the true definition and please let us let our listeners know what resources you have gathered and where they can find them. Obviously, first and foremost, we have our CPT book that gives us a definition of what modifier 25 is.

But, uh, one of the main sources that I go to is the reporting CPT modifier document that the AMA has put out that gives a lot of information about the modifier. So that will be linked in the podcast notes. So the definition. The Wordy definition that we are given is a significant, separately identifiable E& M service by the same physician on the same day of the procedure or other therapeutic service.

Both services must be significant, separate, and distinct. Break that down, Jaci. What does that mean? Well, I hear the word distinct and I hear the word separate.

In my mind, these words make perfectly good sense. You're performing a procedure. And your evaluation and management service is separate from that. Okay, so we take those words, we apply them to common everyday language use, and I need to see that something is separate than the other thing.

That makes sense to me. Then we say, well then, if it needs to be separate, What's it being separate from? So I ask myself then, well, what's a procedure? Well, in CPT, we have a world of a package, a surgical package.

So if something's being performed in the office, let's just say we're going to think it's a minor procedure. What's included in that? What do I need to be separate from? Do they give us that language?

They absolutely do, and so from the AMA, we have a nice little list of what is typically associated with a procedure and would not be included in with that separate E& M. And so the things included of that are a review of the patient's relevant past medical history, an assessment of the problem area to be treated by that surgical procedure or service, um, that's that formulation and explanation of the clinical diagnosis related to that procedure, uh, that review and explanation of that procedure to the patient, family, or caregiver with that discussion of alternative treatments or diagnostic options, getting that informed consent.

Providing that post op care instructions and then discussion of any further treatment and follow up after the procedure. That's a lot of things that are included within that pre and post operative services. But there's a lot of things that aren't included as well. So, it doesn't make anything easy, but at least we have a definition to work with.

So, we have a definition of what the modifier is. They've told us what a surgical package is. And my documentation, if I were the clinician, needs to show that I worked outside of that package. Basically, they've given me everything I need.

So, my final question is, what's the big deal? Why is this still such a problem? In your opinion, what is the big deal? Why are we still scrambling around trying to figure out the proper way to use this modifier and get documentation?

I have my thoughts on that. What's your thought on why is it such a big deal still? Why? Because insurance companies have different opinions on what is appropriate and what's not, and nothing is consistent across the board.

So, and I would say it's the same thing between you and me as auditors and coders. We have our own interpretation of how much more I want to see versus how much more is really required. I think we, this is an opinionated modifier and therefore we get ourselves very wrapped up and very confused. So I think.

Maybe we should start with those things that make the more logical sense. So give me a couple of examples that make logical good sense. Where do we see this used more often than anywhere else? Absolutely.

So one scenario where it is used a lot is when a patient presents to the office to have their preventative medicine visit or their annual wellness visit and they have additional concerns to address outside of those preventative, uh, discussions. So, you would bill your preventative visit or your wellness visit and then you would bill an E& M visit for those additional concerns addressed and the modifier 25 would go on that office visit. That's one very common scenario that we see.

a lot. Another scenario is where a patient comes in for a specific procedure or complaint and then they have a completely different complaint that happens and is addressed outside of that procedure. So say the patient comes in and is having a lesion removed on their leg. They also say, Oh, but my, I think my blood pressure is a little high.

Those are clearly two separate conditions being addressed. And that wouldn't be a question to anybody looking at it, that there were two separate things addressed at the visit and would definitely support significant and separate evaluation and management from the procedure. You think of any good examples, Jaci? I like your dermatology example.

And I think you've used this example before the patient comes in for a scheduled lesion removal. And at the same time, notice, they have now developed a rash. So then the rash. So here's my question from an audit perspective.

Let's say I can have that visit, whether for the rash or the high blood pressure when I'm leveling that service, do I include the work involved in the procedure? Or is it only leveling the service for the new problem? Because that's I'm giving them the visit for that other thing. This is not a clearly established rule and we know that.

So I'm just asking what's your thought on that? Again, Depends on whether or not the procedure was decided upon before the visit happened, or if the decision for the procedure happened during the visit, so patient comes in for a visit where they already know that they're having a lesion removed, then we wouldn't include the decision for a procedure in your evaluation and management leveling of that visit. However, if the patient came in and said, Hey, I have a lesion and I also have a rash, what can I do about both of these issues that we are evaluating?

If the determination to have a lesion removed and a prescription for the rash, you could use the decision for both of those things in your leveling of your service. And let's just say right now the caveat in all of this is the documentation is saying what we're saying, because as we know, everything depends on that documentation for sure. So let's think about the things that we don't want to think about. Let's, let's, let's go into that area where nobody wants to go, but we're going to be brave enough and we're going to go there.

Okay. No, I don't want to. Yeah, but you're going to agree that you would. We had this talk.

I know. Okay. So, Okay. We have a patient who is coming in for steroid injections in the knee.

They've had two every three months or so and now they're coming in and the patient says, it wore off a couple weeks ago. I'd like to have another one. What do you think about that? So, again, obviously the caveat of what the documentation shows, but there are some scenarios where if the patient presents routinely for their shots every three months or set amount of time, it can be appropriate for an evaluation and management service to be billed based on a re evaluation of the problem or complaint because there is either a worsening condition or a change in the progression of, um, the concerning problem.

So say the patient is having lessened response to the treatment and now you need to discuss whether or not they're going to go forward with surgery. If that's clearly documented, you could have something to support an additional E& M. Or if maybe they want to discuss different treatment options, such as maybe going to pain medicine, or maybe trying a different medication, or a different style of injection. Those are different things that we would want to see within the documentation to be able to support something beyond the treatment options.

Just the, let's check and see if you're okay to do another injection. So, if the visit is, we're doing the injection, follow up with me in three weeks, let's see how it does. The patient presents in three weeks and said that only gave me two days of relief. And the provider chooses a different drug to inject.

That's an awful question because I'm gonna, I'm standing by it. So, What do you think? And I know this is an opinion and I've heard lots of different things. They're choosing to inject, again, but they're changing the medication that's getting injected due to what they did prior only gave a couple of days of relief.

So what I'm thinking, would you please go back to what's included in that package? Absolutely. Where it talks about what they did what's included in that conversation like post procedure? So reviewing the relevant past medical history, assessment of the problem area, formulation and explanation of the diagnosis, explanation of the procedure, discussion of alternative treatments and diagnostic options, obtaining informed consent.

None of it says updating a treatment plan. Right. So my opinion is that if the documentation supports that clinical judgment of the rationale of changing the medication based on a change in the patient's clinical diagnosis or status of the condition, we might have a leg to stand on to bill that additional unit. And I guess what I'm thinking, I'm right along with you, however, and again, opinion, because it's an opinionated modifier.

If the provider just changes the medication that's being injected, the drug, and doesn't really document a rationale for that. When I'm auditing or when you're auditing, are you looking for that if they don't explain that they chose to change? Aren't we looking for a rationale to explain why something was changed versus just something else is injected and leaving it up to me, the auditor to go back to a prior visit to see what was injected before? It's up to the clinician to give me some sort of indication that there needs to be something above and beyond just that injection.

Billing an E& M on top of a procedure is a documentation based modifier and additional payment. So it relies on documentation from the clinician to support that additional work was done. And it is not, on the auditor or the insurance company to go look at previous notes to compare and say, oh, did they make a change? Did they do something different?

It needs to be clearly indicated that something above and beyond was done in that treatment. I agree. And it makes sense, and I think I would like to just comment right now that if anyone's listening to this podcast or watching the podcast and has comments or things, please send us back some information. We'd love to get other people involved in this very exciting conversation of modifier 25 because it does require a lot of detail work to honestly understand if that modifier is required or not.

It's not just, Oh, I had a visit and a procedure there I have a 25 modifier, a lot of work goes into that. So we'd love to have your comments and feedback as well. And if you disagree with us, that's fine. I mean, we're being very honest that some of this is an opinion, but if you disagree and have a different thought, we'd love that.

And in a future podcast, we'll bring it up again. Absolutely. Absolutely. We're not saying saying that we know, we are the final, you know, it stops here, it's, these are the things that need to be considered before saying yay or nay to that modifier.

Absolutely. And honestly, when we look at a note ourselves, we can even have a discussion between, the 2 of us or other auditors about what our opinion is based on what we're looking at that day. And so, honestly, this is like Jaci said at the beginning. It is such an open to interpretation modifier and it is very opinion based.

It is. So, speaking of opinions and this modifier. Let's go one other place that maybe you don't want to go, but let's talk about urgent care. I really feel bad for those folks.

A lot of times I do. They're very difficult to audit and they're in a strange situation. However, when we try to apply these rules, let's think about a patient who walks into urgent care. They've got a cut on their hand.

I mean, it just, it just happened. They came in on their own. It's not a head wound. It's on their hand.

How much additional work? I get stymied with these. I'm like, I'm stuck. Like, what do you want me to do?

It was a open wound that wasn't deep. You didn't see tendons. It was a pretty super, but it might need a stitch or 2 and you're going to clean it. What more can be done in that documentation to say, You can have that modifier 25.

So at this point, I think we should bring into this conversation that somewhat rule of new patients and modifier 25. So I put a lot of stuff in there. And Erika, you're just the gal to handle that lacerations are not my favorite topic when it comes to modifier 25 because in that definition of that pre and post operative services typically associated with the procedure has that statement of assessment of the problem area to be treated by surgical or other service. So, if you are just assessing that small laceration on the forearm, and then it's just getting treated.

What else is in your documentation to support something above and beyond that? Even if it is a new patient, what do you have going on in your note above and beyond that assessment of that small laceration? You tell me what else is in your documentation. So, does the patient, if it's a young, healthy patient, that's one thing.

Let's say it's an older patient and they're on blood thinners. That's an example that I just had with a client is that patient was, you know, an older patient who recently started blood thinners and came in for a laceration that would not stop bleeding. That is something that is a bit more complicated than a 12 year old who got a cut from scissors at craft time, you know, Exactly. Or the elderly patient that upon questioning they were dizzy and fell and cut themselves.

Exactly. So we're not saying it can't happen. We're saying we have to be very aware of what the guidelines are. And it is difficult, especially for urgent care.

I really do feel for those providers if they're in a difficult situation. We still only have the documentation to rely upon those. So there's not a whole lot else going on there that we can do. When it comes to those well visits and so called sick visits, when you're looking at that documentation, let's say the provider makes the statement, in addition to the patient presenting for their annual well visit today, they also presented for a follow up recheck of the following chronic conditions.

And let's say they list them. And next to each one, they document patient on this medicine, patient on the, and that's all you get is a list of chronic conditions and the medications that they're on. Don't you love me right now? I don't really.

This is in theory, well, gold standard documentation would be a status and telling me the dosage of the medication. Right. To tell me what is happening and ensuring me that you are the person managing that problem. However, we can gather that or we're allowed to say that a patient is stable on a condition.

And if a medication is connected to a problem, we're able to put those two together to say that there's management. It's not the greatest documentation. I would err on the side of saying, okay, give some education and allow it, but it's not a great support for utilizing modifier 25. An insurance company would come back and say, Whoa, whoa, whoa, whoa, whoa.

What is that extra? What extra work did you do here? I'm not seeing, you know, additional evaluation of these, these problems. So I generally err on the side of giving credit to the clinician, but say, Hey, you're going to want to, right.

Clean that up, clean that up quite a bit. Because you also want to know if they're managing those medications. Are they managing those conditions? There's a lot of others, but I agree with you.

We have to be careful because sometimes it's just a documentation issue and they have performed the work and, but we need to get there. This certainly is not going to turn into an E& M conversation because that's in and of itself beyond anything we have time for right now, but I think it is important. And so I think the one thing we continue to say here is documentation. And, uh, and there are so many examples that we could talk about that make for potential, you know, E& M.

But I think E& M and a procedure that, and depending on the specialty you're in, you're going to have your own examples. I think one thing that I see, and you and I have spoken about before. And we mentioned again, different payers have different interpretation, and this is not a knock on payers at all. They have a job to do.

They're a business. Physicians are a business. Everybody's in the business of health care. But I have found that there are instances where a 25 modifier is appended to a visit and they did an EKG or they did a radiology study.

Is it your thought, Erika, that in these cases a payer is asking for that? And I would hope that that's the case because that's not following coding guidelines. So I'm guessing that that would be the reason I've seen scenarios where they put a modifier 25 on both the PreventMed and the E& M of the additional visit. And I found that that was a specific payer asking for that.

Right. I mean, you can only follow what the payer asks. If you want to get reimbursed. So, you know, the rule there is do look at your payer policies and right, and I'm just going to digress for just a moment and remind everybody, look at your denials.

I think we get lost sometimes. If you look at your denials, why something was denied because they wanted a 25 modifier before you just slap it on there, try to figure out why they wanted it so that you can learn that and proceed with it or question it one way or the other. The other thing that I want to say about documentation, because we seem to talk, talk, talk, talk, documentation, documentation. So when you're doing an audit, what key words help you know there's a 25 modifier and what key words kind of tell you, I don't know if we're going there today, not sure we're going to get that 25 modifier.

What, what things do you look for in particular? So some things that I look for are you know, significant and separate, or if they're talking about additional topics addressed, or even just multiple diagnoses beyond the procedure related diagnosis. But I do want to mention that you don't need to have multiple diagnoses. They could be could all be one diagnosis.

That's not a hard and fast rule where you have to have multiple diagnoses. But that is something that kind of keys my auditor brain is that if there are multiple topics being addressed. But one area that I definitely notice where it could put up a red flag is time based billing and a procedure. So it's really important to note that if you are intending to bill based on time, And also wanting to bill a procedure that your total time statement indicates that your total time does not include any separately billable procedures because I've done audits where they wanted to bill based on time, but they didn't have that caveat of the procedure separately billable procedures portion.

So I wasn't able to utilize the time statement without knowing if the procedure was included in that time statement. True. And I think for me, when I'm looking at documentation, especially, and I just used it in my example with the well visits and the, um, the sick visit, in addition to, you know, anything, simple words like that help. What offsets me is when it starts patient presents today for her injection, patient presents today, requesting the next injection, pa-, you know, anything that leads someone to believe this is planned and we're going to do it now with that.

I'll go back to example we used before. Let's say a patient with the knee pain. It could be osteoarthritis. Give it any diagnosis you want is coming back and they come in and they say, you know what?

I've been putting surgery off now I'm ready and they have that discussion on surgery and the provider says, okay, let's get this scheduled for what? 2 weeks out. In the meantime, I'm going to give you 1 more injection to help you until that time. I think in that case, I would be more open based on the documentation to a visit in a 25 modifier because they've explained why they're doing it.

We've heard about something different and like what you're saying, I see something beyond. Same diagnosis. We haven't changed it. It's just a plan of care has changed and it's been well documented and they've, they've documented everything they're supposed to there.

How about cerumen removal, Jaci? I don't want to talk about that. That's just a mean. So okay, you got me back.

Cerumen removal. First, is it Medicare or not Medicare? You know, Medicare has very clear rules about cerumen removal, and I can barely even say those words together. If that patient presents with an earache, Medicare patient, and you clean out their ears and suddenly they feel better and they can hear better, that's a cerumen removal only.

And remember to document what instruments were used. There's also the G code they want to use. If, you know, if things are done a certain way, you've got to know your Medicare rules. For non Medicare patients kind of the same rules apply.

Patient presents with a complaint. And this took care of the complaint, you've got to know what else, were they dizzy? Do they have hearing loss? Is all better?

You know, you took care of the issue, but if the patient has something that's ongoing, in addition to hearing loss, known hearing loss for other reasons, you potentially have a visit. I can't tell you, I've been doing a lot of ENT and a lot of Medicare patients just have it scheduled. I come in every month and get my ears cleaned. There is An audiologist sent me to have my ears cleaned before my hearing aid check.

Exactly. Before I get my hearing aids done, I would need to have my ears cleaned and they come in to have that done. It's kind of like, I hate to say it, but it's kind of like being a draw station for a lab. You come, you are the people they come to, to get the ears cleaned and that's all there is.

And it's cerumen removal and it doesn't typically warrant an extra visit if we know that's the reason for it. It has to show that something else was going on and something else was being done. Now, say they do the cerumen removal and they determine that there's an ear infection because they find, you know, Perfect. Yeah.

Then they do a prescription. And they're going to order an antibiotic. Yeah. Mm hmm.

You know? Yeah. That's totally different. Yeah.

That's a great example. All right. We've talked about ears and urgent care and knees and well visits and sick visits. I think we've covered the gamut.

Even though there's plenty more depending on your specialty, you could fit it into those. Can you think of anything else? I don't think so. I think we've covered the areas we wanted to.

And I do want to say, this is the first time we're trying not just the audio, but you're going to see us as well, which we enjoy being the beta for that. But I do want to explain my situation here. My grandsons were here a few weeks ago, and they rolled over my headphone. They ran out with my chair and I didn't know that until I put these on and they're kind of loopy now.

So that's why I'm doing the holding on over here. Um, it's not that I didn't want to wear them. I would wear them, but they look kind of sloppy funny, but we just want to bring you information that we know that's on your minds. And I think it's important that we talk about these things and again, stressing, we'd love to get some feedback.

I think. The 1 thing about I love about what we do, and I think we may have mentioned this on the podcast before. It's a networking type of career. So to speak, we have to talk together, figure things out together.

So we really appreciate feedback. Whatever it is again, if we misspoke, um, if you totally disagree, we will certainly bring that up in a future podcast and apologize in advance. But we did follow the rules. We please reference what we were speaking to.

Erika has it in the podcast notes or notes. Yeah, notes. Yeah, I think that's right. I don't do that part of it.

Real technical. Yeah, and I'm not. So anything else. I don't think so.

Well, we have a teaser on what our next topic is going to be. It's called the show notes. Thank you. That's the show notes.

I think the next topic would be, um, incident to and split shared. Oh, I knew you were going to say that. I was gonna. Cause it just keeps coming, just keeps coming back.

Just won't, just won't settle itself down. So that's the teaser for next time incident to and split shared. Always a pleasure, Erika. I love your brain.

You're fantastic. Oh, so are you. You're such a great resource. It's so powerful.

So thank you everyone for your time. And again, let us know if you have any questions or feedback and enjoy your day wherever you are. Bye, everybody. Bye.

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