APMA News - November/December 2020 - 21

Modifier Revisited

By Luke Hunter, DPM; Lawrence Santi, DPM;
and Paul Kinberg, DPM

T

he 25 modifier, a modifier that is often overused and
abused, has started to undergo increased scrutiny by
Medicare and private payers alike. In some cases, physicians have even found their evaluation and management (E/M) payments reduced when billed with the 25 modifier due to overuse, or sometimes under-documentation.
The 25 modifier, when appended to an E/M code, indicates
it is a " significant, separately identifiable evaluation and management service by the same physician on the same day of the
procedure or other service. "
A recent APMA Coding Resource Center survey asked respondents to indicate whether the following statement is true
or false: " The 'significant and separately identifiable' concept
as it relates to an E/M service performed at the same time as a
procedure does not apply to new patients. " The results were
as follows: false-70.9 percent; true-29.1 percent.
The answer can be found in chapter 1 of the NCCI policy
manual, which states: " Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E/M service for
the work associated with the decision to perform a minor
surgical procedure [i.e., has a global period of 000 or 010
days], whether the patient is a new or established patient. " (Emphasis added.)
So when can we bill an E/M along with a procedure? Chapter 1 also states that " a significant and separately identifiable
E/M service unrelated to the decision to perform the minor
surgical procedure is separately reportable with modifier 25. "
This statement describes a situation where there is no overlap
in the work associated with the E/M and the work associated
with the procedure. If you evaluate a separate problem (e.g.,
a bunion) along with an ingrown nail, document both, and
discuss the treatment options for the ingrown nail and then
perform a matrixectomy, it is easily justifiable to bill an E/M.
Chapter 1 goes on to state, " the E/M service and minor
surgical procedure do not require different diagnoses " and

continued on page 22
APMA News November/December 2020

21



APMA News - November/December 2020

Table of Contents for the Digital Edition of APMA News - November/December 2020

Contents
APMA News - November/December 2020 - Cover1
APMA News - November/December 2020 - Cover2
APMA News - November/December 2020 - 3
APMA News - November/December 2020 - 4
APMA News - November/December 2020 - 5
APMA News - November/December 2020 - 6
APMA News - November/December 2020 - 7
APMA News - November/December 2020 - Contents
APMA News - November/December 2020 - 9
APMA News - November/December 2020 - 10
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APMA News - November/December 2020 - 12
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APMA News - November/December 2020 - Cover3
APMA News - November/December 2020 - Cover4
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