AE May/June 2021 Vol 30 No 3 - 44

SPECIALTY PRACTICE // RETINA

MODIFIER -25- DOES YOUR
DOCUMENTATION SUPPORT IT?
L. Elizabeth Cifers, MBA, MSW, CHC, CPC

T

he debate in retina practices
about billing an office visit
with a -25 modifier
is ongoing.
In my professional
experience, most documentation fails to substantiate
using a -25 modifier. Establishing
a clear understanding of modifier
-25 and the requisite documentation to support both the office
visit and the procedure is essential
for good documentation.
DEFINITION
Let's review the -25 modifier and
the -57 modifier to compare and
contrast the two modifiers. The
Current Procedural Terminology
(CPT) codebook states:
-25 Modifier - Significant,
Separately Identifiable
Evaluation and Management
Service by the Same Physician
or Other Qualified Health Care
Professional on the Same Day of
the Procedure or Other Service.
It may be necessary to indicate that
on the day a procedure or service
identified by a CPT code was
performed, the patient's condition
required a significant, separately
identifiable E/M service above and
beyond the other service provided
or beyond the usual preoperative
and postoperative care associated
with the procedure that was

44

AE // May/June 21

performed. . . Note: This modifier is not used to report an E/M
service that resulted in a decision to
perform surgery. See Modifier 57.
-57 Modifier - Decision for
Surgery.
An evaluation and management
service that resulted in the initial
decision to perform the surgery
may be identified by adding modifier 57 to the appropriate level of
E/M service.1
COMPARE/CONTRAST
The indications for modifiers -25
and -57 are distinct. The global
surgery package for 0- and 10-day
procedures includes the visit on the
day of the procedure.2 Thus, if an
office visit takes place on the same
day as a minor procedure, e.g., intravitreal injection, the documentation
to support the visit must be above
and beyond. In contrast, the -57
modifier indicates the office visit was
when the decision for surgery took
place. In the retina practice, this may
be an emergent situation where the
patient will undergo major surgery
on the same day.
The similarity of modifiers
-25 and -57 is that both are for
use with an E/M (or Eye Code)
service. Additionally, the modifiers
unbundle National Correct Coding
Initiative (NCCI) edits where the
E/M visit is a procedure component.

CRITICAL DISTINCTIONS
The critical words in the -25 modifier description are " significant " and
" separately identifiable. " The office
visit documentation on the same
day as a procedure must pass this
litmus test; to do that, you need to
ask a few simple questions.
*	 Why is the patient being seen?
The chief complaint
establishes the medical need
for the visit, whether an
office visit or a procedure.
Suppose a patient comes in
for a scheduled procedure,
voices an unrelated complaint, necessitating that the
physician examine, diagnose,
and create a treatment plan
for the new complaint; if the
documentation supports the
additional work, a -25 modifier is appropriate. If a patient
comes in for a scheduled
procedure, has no unrelated
complaints, then a -25 modifier is not applicable.
*	 Is the E/M meaningful
and beyond the customary
pre-and post-op work for a
minor procedure?
Creating supportive
documentation for the office
visit is critical to support
the " significant " and " separately identifiable " office visit
service. Creating a timetable



AE May/June 2021 Vol 30 No 3

Table of Contents for the Digital Edition of AE May/June 2021 Vol 30 No 3

AE May/June 2021 Vol 30 No 3 - Cover1
AE May/June 2021 Vol 30 No 3 - Cover2
AE May/June 2021 Vol 30 No 3 - 1
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