E/M Services and Drug Administration Billing

It may be appropriate to append modifier 25 to an E/M service when a separately identifiable, medically necessary service has been provided in addition to a procedure provided on the same date. The physician/NPP's documentation must indicate that on the day a procedure (identified by a CPT code) was performed, the patient's condition required a significant, separately identifiable E/M service. Typically, an "interval history" with pertinent, focused exam is already a portion of the pre-service work of performing any procedure and not separately billable. In contrast, a separately billable E/M service does not relate directly to the actual performance of the procedure. This circumstance may be reported by appending modifier 25 to the appropriate level of the follow-up E/M service. Commonly, the separately identifiable nature of a service is indicated by a separate diagnosis code. Rarely, an E/M service separate from the procedure may be associated with the same diagnosis code.

Examples of Billing E/M Services with Modifier 25 (not an all inclusive list)

  • It is not appropriate to append modifier 25 to an E/M service for use of a room, technician time, nursing care, assessment, or monitoring, nor for the routine "interval history" of "is everything OK" since the last visit/treatment when there is no other more significant service.

    Example: The patient arrives for chemotherapy treatment. The nurse completes an assessment including vital signs, confirms there are no new or interval issues; starts the treatment and continues to periodically monitor the patient during the treatment. A separately identifiable E/M service has not been provided and should not be billed with modifier 25.

  • It is appropriate to append modifier 25 to an E/M service billed on the same day as a drug administration code when documentation clearly supports a medically necessary E/M service unrelated to the chemotherapy administration. This may include physician/NPP evaluation and management of the disease process requiring the administration for the drug if an alteration of the treatment plan may be required due to symptoms/signs, adverse treatment reactions, etc. A routine interval evaluation, for example to assure there are no new issues when the patient presents for chemotherapy, may not be separately paid by Medicare and must not be billed.

    Example: The patient arrives for chemotherapy treatment, newly refusing to continue home medication regimen due to side-effects. The physician/NPP evaluates the patient complaint and makes a determination on potential changes in the treatment plan. The patient also receives chemotherapy. In addition to the administration of the chemotherapy, the modifier 25 may be appended to the physician /NPP submitted E/M service.

Note for Part B Providers: Modifier 25 should only be appended to an E/M services with 0 or 10 day global period. It would be inappropriate to append it to a services with a 90 day global period; this type of procedure would require a modifier 57. Appending modifier 25 to a new patient E/M visit is not necessary.

Resources

Revision History Number Revision History Date Revision History Explanation
3 06/10/2014 Revised for clarity.
2 11/01/2013 This article was revised to reflect the corporate name change from Noridian Administrative Services, LLC to Noridian Healthcare Solutions, LLC that was effective on 05/01/2013.
1 02/27/2012 02/27/2012 – In accordance with Section 911 of the Medicare Modernization Act of 2003,The contractor numbers 02101, 02201, 02301 and 02401 were added to this article as the claims processing for the states of AK, ID, OR and WA are transitioned to MAC JF.

 

Last Updated Mar 03, 2020