When it comes to podiatry billing, even seemingly small details can have a significant impact on your revenue, and that’s particularly true when it comes to the correct use of Modifier 25.

Are you leaving money on the table by misusing it or, even worse, being afraid to use it at all for fear of triggering audits? In this blog post, A Step Above Health Management will clarify when and how to use Modifier 25 and demonstrate how outsourcing your billing can help you maximize reimbursements and reduce denials.

What is Modifier 25?

Modifier 25 is appended to an Evaluation and Management (E/M) CPT code to indicate that a significant, separately identifiable E/M service was performed on the same day as a procedure.

Essentially, it tells the insurance payer, “Hey, I did more than just the procedure today; I performed a separate, billable E/M service, too!”

When to Use Modifier 25 in Podiatry

Here’s the tricky part: The E/M service must be truly separate and significant.

Here are some examples of when it is and is not appropriate:

• Appropriate:
  • A patient presents for routine diabetic foot care (e.g., nail debridement or callous care) but also complains of new or worsening heel pain. You perform a separate evaluation to diagnose the heel pain. The E/M visit would get a -25 modifier.
  • Patient presents for follow-up of an ulcer debridement. During the visit, they complain of new numbness and tingling in the other foot. The follow-up visit would be billed with a -25 modifier.
• NOT Appropriate:
  • Patient presents for routine diabetic foot care. No new complaints. This does not get a -25 modifier.
  • Patient presents for an injection. The doctor performs the injection and does a brief exam. This would also not get a -25 modifier.

Documentation is Key!

Your documentation must clearly support the medical necessity of a separate E/M service.

Think of it this way: Could another provider, looking at your notes, easily identify the distinct E/M service you performed in addition to the procedure?

Here’s what your documentation should reflect:

• A detailed description of the separate E/M service, including history, exam, and medical decision-making related to the new problem or a significant worsening of a pre-existing problem.
• Clear separation between the documentation for the procedure and the E/M service.
• A distinct diagnosis that is separate from the condition for which the procedure was performed.

The Outsourced Billing Advantage

Navigating the nuances of Modifier 25 can be challenging. This is where an outsourced podiatry billing and coding firm like ours can be invaluable.

Benefits of Outsourcing:

• Expertise: Our certified coders are experts in podiatry billing and stay up-to-date on the latest coding guidelines.
• Accuracy: We ensure accurate coding and modifier usage, maximizing your reimbursements and reducing denials.
• Compliance: We help you maintain compliance with complex billing regulations, minimizing your audit risk.
• Increased Revenue: By optimizing your billing processes, we help you capture all the revenue you’ve earned.

Modifier 25, when used correctly, can significantly impact your practice’s bottom line. However, improper use can lead to denials and audits. To prevent those from slowing you down and learn more about Modifier 25, please feel free to get in touch. We’d be happy to assist!

We can help you avoid billing errors. A Step Above Health Management provides specialized podiatric medical billing services to clients nationwide. Let our firm provide your practice with a plan customized to manage all your billing needs. Please call us at (877) 448-6233 to learn how our solution can save you money and help streamline your billing process.