Wound Care and Modifier 25
Modifier 25 Description
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 performed.
Wound Care and E/M Services
Wound care patients often have underlying medical conditions that require additional management and may also require education, other services, and coordination of care. If the provider is managing wound care in addition to other conditions, the provider may report an E/M service with modifier 25. This modifier is used to facilitate billing of E/M services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable E/M service by the same physician on the day of a procedure.
The physician may need to indicate that on the same day a procedure or service that is identified with a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. This circumstance may be reported by appending the modifier 25 to the appropriate level of evaluation and management service.
If the sole purpose of the visit is wound care management, only the wound care codes should be reported. Data reflects improper billing of wound care and E/M codes on the same date of service. Patients who have chronic wounds may frequently have underlying medical problems that require concomitant management in order to bring about wound closure. In addition, patients may require education, other services, and coordination of care both in the preoperative and postoperative phases of the debridement procedure. An E/M service provided and documented on the same day as a debridement service may be covered by Medicare only when the documentation clearly establishes the service as a ‘separately identifiable service’ that was reasonable and necessary, as well as distinct, from the debridement service(s) provided.
The following procedures are considered part of an E/M service and are not separately covered when an E/M service is performed:
- Removal of necrotic tissue by cleansing and dressing, including wet or dry-to-dry dressing changes,
- Cleansing and dressing small or superficial lesions, and
- Removal of coagulated serum from normal skin surrounding an ulcer
Providers billing for wound care and E/M on the same date of service are advised to review their scenarios and documentation to verify that what has transpired and been recorded supports what has been coded and billed.
Modifier 25: Avoid Overuse or Misuse
Medicare and other providers have increased scrutiny of modifier 25, which is used when something ‘distinct and different’ is needed on the same day as an evaluation and management (E&M) service. The Office of the Inspector General (OIG) has identified modifier 25 as a potential area of overuse or misuse, thereby increasing the potential for audits. We strongly recommend using modifier 25 on an extremely limited basis. It’s only appropriate in about 10 percent of cases.
Generally, wound care involves assessment and management of the wound, cleansing of the wound, simple debridement, and removal and reapplication of the wound dressings. In most cases, it is inappropriate to report an E/M service in addition to a wound care service (e.g., debridement, application of an Unna’s boot, etc.); however, if during the wound care encounter the provider performs a significant, separately identifiable service, and the provider documents this in the patient’s medical record, it may be appropriate to report an E/M service with modifier 25.
In conclusion, if you use modifier 25, make sure it’s a distinct service outside of what your normal wound care service would be. Remember, when it comes to using modifier 25, it all boils down to documentation and justification of medical necessity for a previously unrelated or undiagnosed condition.
Modifiers © Copyright 2021 American Medical Association
Unfortunately, not all insurers will pay you for the separate E/M service even if you code in compliance with CPT rules. Be sure to have your staff appeal any denied or bundled claims. A review of your documentation by the insurer may actually result in payment for your work. Still, confused about modifer 25? Don’t worry E2E Medical Billing Services has an experienced coding team that uses exact modifiers to avoid denials. To know more about our medical billing services call us at 888-552-1290 or write to us at [email protected]