Master the upcoming ICD-10 code and IPPS changes! Prepare your team for the upcoming changes taking effect on October 1. Discover the benefits of IPPSPalooza and how it can drive your success. Click here >

Modifier 25: Chose Wisely from Three Options

Whatever you do, don’t bring patients back for a procedure another day just for the purposes of billing.

Determining when to use Modifier 25 can be challenging, and reasonable people can differ about whether it is appropriate in a particular situation.

When a patient needs a procedure on the day of an evaluation and management (E&M) service, you generally have three options. You may opt to bill only the procedure; that is certainly legal, though it may well leave you underpaid. You can provide both services on the same day, billing both using Modifier 25; that, of course, puts you on the Modifier 25 radar, which is perfectly acceptable as long as it was proper to append the modifier. The third and final option is to tell the patient they need to come back on a different day for the procedure. Which option is “right?” How would you rank those choices?

It isn’t reasonable to fully answer the question in the abstract. The best option will depend on the procedure and the reason for the E&M service. But regardless of the procedure, there is one thing that I will always discourage: I cannot envision a scenario in which I would recommend telling a patient to come back on a later day for a procedure simply because of the billing issue. If the procedure and visit are both billable, they are both billable on the same day with Modifier 25. If they are bundled, forcing the patient to return does not change that fact. I would much rather defend a practice for using Modifier 25 than bring the patient back.

First, and most obviously, we should always put the patient first. Making the patient come back is terrible patient care, and quality should be paramount in any medical setting. But that is not all. (This assumes that it is realistic to perform the procedure on the day in question. If it is not medically appropriate to perform the procedure the same day, obviously, the procedure should be delayed.)

Think about how you would view this case if you were a juror. The billing rules are complicated. You are not sure whether to believe the government or the physician. Which physician would you trust more: the doctor who performed both procedures and used Modifier 25, openly disclosing all of the relevant facts on the claim form, or the physician who tried to obscure the bundling question by splitting the two visits? I know that I would have a very negative view of that second physician. I would think that the effort to obscure facts implies a guilty conscience, and a tendency to prioritize profit over patients. In short, after hearing the facts, I would deeply doubt the integrity of the physician, and I would be more likely to trust the government.  

The bottom line is that it is a viable option to not to bill for or eat the E&M service. I am not recommending that, because I think you should get paid for your work. I prefer the option of billing, attaching Modifier 25, and fighting for the reimbursement. But I would strongly discourage you from inconveniencing the patient and bringing them back on another day.

As a final note, I recognize that there are some False Claims Act (FCA) cases involving Modifier 25. But as long as the guidance is as poorly written as it is, organizations should aggressively fight against any such FCA case. The recent Department of Justice memo by Rachel Brand reiterates what should be an obvious principle: government guidance should not form the basis of government action against medical professionals.

When the guidance is poorly written and confusing, that principle is even more applicable.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn
Email
Print

David M. Glaser, Esq.

David M. Glaser is a shareholder in Fredrikson & Byron's Health Law Group. David assists clinics, hospitals, and other health care entities negotiate the maze of healthcare regulations, providing advice about risk management, reimbursement, and business planning issues. He has considerable experience in healthcare regulation and litigation, including compliance, criminal and civil fraud investigations, and reimbursement disputes. David's goal is to explain the government's enforcement position, and to analyze whether this position is supported by the law or represents government overreaching. David is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Explore comprehensive guidelines and best practices for secondary diagnosis coding in our illuminating webcast. Delve into the intricacies of accurately assigning secondary diagnosis codes to ensure precise medical documentation. Learn how to navigate complex scenarios and adhere to coding regulations while enhancing coding proficiency. Our expert-led webcast covers essential insights, including documentation requirements, sequencing strategies, and industry updates. Elevate your coding skills and stay current with the latest coding advancements so you can determine the correct DRG assignment to optimize reimbursement, support medical decision-making, and maintain compliance.

Print Friendly, PDF & Email
September 20, 2023
Principal Diagnosis Coding: Mastering Selection and Sequencing

Principal Diagnosis Coding: Mastering Selection and Sequencing

Enhance your inpatient coding precision and revenue with Principal Diagnosis Coding: Mastering Selection and Sequencing. Join our expert-led webcast to conquer the challenges of principal diagnosis selection and sequencing. We’ll decode the intricacies of ICD-10-CM guidelines, equipping you with a clear grasp of the rules and the official UHDDS principal diagnosis definition. Uncover the crucial role of coding conventions, master the sequencing of related conditions, and confidently tackle cases with equally valid principal diagnoses.

Print Friendly, PDF & Email
September 14, 2023
2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY24 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.

Print Friendly, PDF & Email
2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts

Print Friendly, PDF & Email
August 17, 2023

Trending News