Pulmonology Coding: Real-life Modifier 25 Scenario

By Author: Angela Martin
Total Articles: 205
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There are three ways to gauge when you are on the right track with reporting modifer 25.


Verify the service


Check for additional work


Look for service ‘pre-planning'


The rationale of modifier 25 is that the doctor may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition called for an important, 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 carried out.


Here's a coding example:


Your surgeon conducts lung biopsy on Mr. Brown. After six weeks of the surgery, Mr Brown returns to your office and sees a different doctor owing to an ankle sprain - a totally unrelated procedure.


Code it: Even though Mr Brown came back to your office within the 90-day global period of the surgical service, he came for a problem unrelated to the lung surgery and went to a different doctor. Although medical coders ...
... see the second visit as ‘separately identifiable' appending modifier 25 is not an option. If you refer to the basic rules of using modifier 25, you will see that the separate and identifiable E/M service must be provided on the same day as a minor procedure.


As you do not have a ‘minor' procedure preceding the visit for ankle sprain, modifier 25 is not apt. The lung biopsy is a major procedure and has a 90-day global period which includes all related postoperative care by the surgeon/group for 90-days post the procedure. Even though the patient saw another surgeon in the same group, the visit for the ankle sprain was not related to the lung surgery and can be reported with the right E/M code and modifier 24.


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