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When You Can Discard Modifier 25

When You Can Discard Modifier 25

Modifier 25 cuts a fine line in the medical billing world. Auditors tend to target medical billing claims with this modifier however CMS recently clarified again that they do indeed want this modifier used where appropriate in medical billing claims.

The best rule for when to use modifier 25 is met when your physician provides a significant and separately identifiable E/M service on the same day as a procedure with a global period. If your services meet that requirement, you are free to use the modifier without worry in your medical billing claims. The CMS updated the usage language of the modifier in the release on August 20, 2006 and the clarification can be read here www.cms.hhs.gov/transmittals/downloads/R954CP.pdf.

A good example would be for a patient to present to an ob-gyn who services the patient for E/M service and identifies polyps in the cervical os. He decides to remove the polyps the same day instead of asking the patient to return. This would be an example that would allow usage of the modifier 25.

There are many occasions where modifier 25 is used inappropriately and it results in false revenues for the practice, this will eventually be caught in audits and the practice will be fined not only the amount but penalties and other fees as well.

Another tip that will help in case of an audit, get your physician to dictate a separate note and back it up with ironclad documentation that shows the reason for the modifier and you’ll never have a problem using modifier 25 in your medical billing claims.

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