Modifiers are codes that, well, modify an E&M code. Modifiers are meant to be used when circumstances affect a service, but not to the extent that it would qualify for a different E&M code.
For example, a 25 y/o male patient decides to see you for a wellness visit, a “checkup.” You do the routine care and exam, discussing all the aspects of preventative care. As you are about to leave, he mentions that he has a boil in the pubic area. Sure enough, he has an inguinal abscess, which you drain. You have done work above and beyond the typical wellness visit. You would code the general adult wellness visit, but you would also code for an I&D abscess.
If you do not use a modifier, the insurance company will simply get a charge for a wellness visit and an I&D abscess on the same day. They would not accept two separate office visit charges on the same day. Typically, there is no reason for a person to see the doctor twice in one day.
The -25 modifier means “a significant, separately identifiable E&M service by the same physician on the same day of another service.”
This modifier typically comes into play during a wellness exam. When a patient makes a wellness appointment you are required to do a thorough exam and preventative care. You are responsible for taking care of their chronic, stable medical problems on this visit. If a person has hypertension, you are responsible for checking their renal function and doing any routine care for hypertension.
However, let’s say a person makes an appointment for “a checkup,” and you do all the required routine care and preventative care. However, during the ROS, he notes that he has developed angina symptoms over the last week. He has a squeezing sensation with excretion and shortness of breath. He also smokes, has diabetes and an LDL of 182. You are going to do work “above and beyond” a typical wellness visit, and you can charge appropriately for that. In order to do so, you would need to attach a -25 modifier to the charge for chest pain.
This is where ICD-9 codes are critical. You attach the wellness E&M code to the ICD-9 code for well adult.
99396 (New patient, well adult screening, 40-64 y/o), V70.0 (ICD-9 code for well adult).
You decide that the amount of history and decision making you do for the chest pain—the work done above and beyond the typical wellness visit—would qualify for a 99213. You wisely code for this on the same billing sheet, noting the modifier and proper ICD-9 code:
99213 -25 , 411.1 (unstable angina)
The insurance company’s computer recognizes this, and the charges have no problem going through.
If a patient is being seen for another problem, they may bring up the chest pain as a condition they would like to be seen for that day. However, you would not use a modifier to add one routine office visit to another. Generally, you would simply code for one office visit at the appropriate level for 2 problems. For example, if a person comes in for a sore throat, but then mentions chest pain, you would likely end up coding for a 99214 for both chest pain and sore throat instead of simply a 99213.
Admittedly, it is sometimes difficult to sort out what is meant by “above and beyond” the typical wellness exam. The typical wellness exam should include a thorough ROS, PFSH, and exam. Does this mean that you cannot claim any elements from a ROS or exam toward the -25 charge? If the ROS and exam are considered part of the wellness exam, we cannot apply those to our routine office visit charges. It is impossible to code anything above a 99212 without a ROS or exam. Although none of this is clearly defined and may vary based on different insurance carriers, the general experience is that it is acceptable to code a 99213 with a V-25 if the documentation appears to warrant it. The physician must be more detailed to be sure to document the extensive work done in these cases. However, in the end, the coding decision may be more subjective than the typical visits.
Medical Coding and Billing For Residents 