Modifier 25, revisited

By Alexander Miller, MD, March 1, 2018

When you do a minor surgical procedure with a zero- or 10-day global period (biopsy, shave removal, lesion destruction, simple excision, a simple, intermediate or complex repair, Mohs surgery) and you also perform a distinct and separately identifiable evaluation and management (E/M) service, you would usually append a 25 modifier to the appropriate CPT^® code (99201-99215) characterizing the level of separate E/M service provided.

Lately, some payers have been focusing upon modifier 25 use, and have implemented or are intending to institute reimbursement limitations, payment reductions, and/or focused chart audits. As we dermatologists use modifier 25 more than any other specialty, we are particularly vulnerable to insurance company limitations on its use. Consequently, it is imperative that our charting justify both the medical necessity for a separately identifiable E/M service and appropriately document that service.

The E/M service provided should “stand on its own.” This means that one should subtract from the overall E/M provided all E/M services included in the valuation of the procedure. What is left, if any, determines the level of billable E/M. The decision to perform a minor surgery based upon a focused evaluation, examination, and diagnosis of a lesion or related lesions is usually included in the procedure code and is not separately billable. Also included are preoperative and routine postoperative care done within a global period. The separately billable E/M service should be supported by essential chart documentation: history, examination, and medical decision making. A diagnosis different from that linked to a procedure is not required for appropriate modifier 25 use.

Modifier 25 applies only to E/M services done in association with minor surgical procedures, those with a zero- or 10-day global period. Separate E/M services done on the same day as a 90-day global period major surgery (flap, graft) are identified with modifier 57. Unlike with minor surgeries, evaluation and management leading to a decision to perform a major surgery is separately billable with modifier 57 when done on the day of or the day before the major surgery.

Example 1: A new patient comes in with a chief complaint of a gradually growing, recurrently bleeding lesion on his nose. You examine the nose and face and diagnose a probable basal cell carcinoma, which you then biopsy. You routinely offer a complete skin examination to new patients, and the patient accepts your offer. The examination reveals multiple seborrheic keratoses on the trunk and solar lentigines on the face. You code CPT 11100 for the biopsy and 99203-25 for the rest of the evaluation, specifying ICD-10 diagnoses L82.1, seborrheic keratosis, and L81.4 for the solar lentigines. The insurer requests a chart review, and then rejects payment for the E/M (99203-25), judging it not medically necessary. What? But you did this separately identified and well-documented work!

Answer: The devil is in the details. The insurer considered the complete skin examination to be a skin screening examination, and screening exams are not a covered service under the patient’s insurance plan. Since the chart stated, “complete skin screening offered, accepted and done,” it implied that the examination was an optional screening instead of a reasonable and necessary service. Had you charted that in view of the suspected skin cancer a complete skin examination was indicated, and was done, this would likely have justified criteria for coverage. It is helpful to document the medical decision making leading to a distinct E/M service, but not always specifically necessary, as in when the need for the separate E/M is clearly validated by the presenting diagnosis, such as a suspected malignant melanoma that leads to a further probing history, complete skin examination, and action plan.

Example 2: You examine a new patient in the Medicare Administrative Contractor Noridian’s jurisdiction (Western U.S.) with psoriasis and discover multiple actinic keratoses, which you freeze with liquid nitrogen. You also manage the patient’s psoriasis. You code CPT 17004 for destruction of 16 actinic keratoses and 99203 for the E/M of the psoriasis.

Answer: Correct. Noridian Medicare does not require appending modifier 25 to a new patient E/M code. Some other Medicare Administrative Contractors and all private insurers require modifier 25 in association with a new patient E/M. All insurers (including Noridian) require that modifier 25 be appended to established patient (CPT 99211-99215) E/M codes, when appropriate.

Example 3: You do an interim history and extensively examine photodamaged skin of the scalp, face, neck, trunk, and extremities of an established patient complaining of multiple scaly lesions and diagnose actinic keratoses. You then freeze 12 actinic keratoses with liquid nitrogen. You bill CPT code 17000 and 17003x11 for the destructions and 99213-25 for the patient evaluation and skin examination.

Answer: Incorrect. No separately identifiable, distinct history and examination E/M service beyond that included in pinpointing the lesions and deciding to perform the cryodestruction was done. Consequently, no level of E/M billing is appropriate.

Example 4: A privately insured new patient with a history of a spreading, diffuse, pruritic eruption is evaluated. Following a detailed new patient history, past medical history, review of systems, and a complete skin, eyes, oral mucosa, nails, and lymph node basins examination you suspect a cutaneous T-cell lymphoma. You biopsy two sites from a broad lesion and code CPT 11100 for the biopsies and 99203-25 for the E/M.

Answer: Correct. There was substantial separately identifiable, medically necessary E/M done and documented beyond that limited to a decision to perform the biopsies. Only one biopsy was coded because multiple biopsies done on a single lesion are billable as only one unit of biopsy, 11100 (NCCI Policy Manual for Medical Services).

Example 5: You do an interim history and a complete skin, oral mucosa, and eyes examination along with lymph node basins palpation on a patient with a history of treated malignant melanoma. The patient had no specific complaints, but was scheduled for a regular examination as follow-up for the previously diagnosed melanoma. You identify one atypical pigmented lesion, which you biopsy. You bill CPT 11100 for the biopsy and 99213-25 for the E/M, linking it to ICD-10 diagnosis Z85.820, personal history of malignant melanoma.

Answer: Correct. Although the patient had no current complaints, the separately identifiable E/M was medically reasonable and necessary based upon a past history of malignant melanoma, which requires a lifetime of vigilance. This situation is different from a non-covered skin screening examination done for the purpose of possibly finding atypical skin lesions in a person with no prior history of relevant skin disease.

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