Modifier 25

[nycdoctor]

If a patient comes for routine foot care and it consist of both nail debridement and cutting of the callus every 2-3 months am I able to use modifier 25?

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[Pronation]

If a patient comes for routine foot care and it consist of both nail debridement and cutting of the callus every 2-3 months am I able to use modifier 25?

Only if you suck on their toes first to soften up the calluses before you give them their pedicure, doctor.

 

[josebiwasabi]

You are definitely an NYC pod.

No, there is no E&M to attach the -25 modifier to. Please don't tell me you are billing a 99212/99213 in addition to a 11721 and 11057 every 61 days.

 

[HardRoadPaved]

Only if you suck on their toes first to soften up the calluses before you give them their pedicure, doctor.

Negative. They expect you to suck for free now. From medicare lcd:

The following services are considered to be components of routine foot care, regardless of the provider rendering the service:

• Cutting or removal of corns and calluses;
• Clipping, trimming, or debridement of nails, including debridement of mycotic nails;
• Shaving, paring, cutting or removal of keratoma, tyloma, and heloma;
• Non-definitive simple, palliative treatments like shaving or paring of plantar warts which do not require thermal or chemical cautery and curettage;
• Other hygienic and preventive maintenance care in the realm of self care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients;
• Any services performed in the absence of localized illness, injury, or symptoms involving the foot.

 

[heybrother]

If a patient comes for routine foot care and it consist of both nail debridement and cutting of the callus every 2-3 months am I able to use modifier 25?

Why don't you tell us what you want or believe or the context leading to you asking this question.

The difference between understanding the 25 modifier is the difference between success and bankruptcy in my opinion. Have you read the CMS documentation explaining the 25 modifier? Or the LCD/rules related to nailcare? We cover this topic on here a lot.

 

[UNVME2]

If a patient comes for routine foot care and it consist of both nail debridement and cutting of the callus every 2-3 months am I able to use modifier 25?

25 modifiers are only added to E&M services (99212, 213, etc) as a way of designating the presence of a new, separately identifiable problem that involves evaluation and management. They are not added to nail debridement/callous codes (11721, 11055, etc) alone.

I will tell you from personal experience the use of billing both E&M codes and debridement codes on the same day is a red flag for medicare and private insurers. Medicare sub-contracts auditers to compare how often you bill both these services compared with other podiatrists in your area. They will then email you with a spreadsheet so you can see how you compare. It does not matter, justified or not, if you are an "outlier" they will give you a gentle warning saying "hey, compared to everyone else, you are over using these codes." They are clear to state this is not an audit, threat of an audit, etc. Just a tool to let you know where you stand. They state in the letter, in the interest of saving medicare funds, you should use these codes with caution. They then recommend you sign up for a free webinar on when it is appropriate to use EM codes with debridement codes.

Many doctors in my practice were under the assumption that once a year you could bill a 99213 (25) with 11721, 11055 if you were doing a "yearly diabetic foot exam." This is not the case. Medicare has outlined when it is appropriate to do so, and expects you know the rules.

 

[air bud]

You are definitely an NYC pod.

No, there is no E&M to attach the -25 modifier to. Please don't tell me you are billing a 99212/99213 in addition to a 11721 and 11057 every 61 days.

Lol

 

[icebreaker32]

25 modifiers are only added to E&M services (99212, 213, etc) as a way of designating the presence of a new, separately identifiable problem that involves evaluation and management. They are not added to nail debridement/callous codes (11721, 11055, etc) alone.

I will tell you from personal experience the use of billing both E&M codes and debridement codes on the same day is a red flag for medicare and private insurers. Medicare sub-contracts auditers to compare how often you bill both these services compared with other podiatrists in your area. They will then email you with a spreadsheet so you can see how you compare. It does not matter, justified or not, if you are an "outlier" they will give you a gentle warning saying "hey, compared to everyone else, you are over using these codes." They are clear to state this is not an audit, threat of an audit, etc. Just a tool to let you know where you stand. They state in the letter, in the interest of saving medicare funds, you should use these codes with caution. They then recommend you sign up for a free webinar on when it is appropriate to use EM codes with debridement codes.

Many doctors in my practice were under the assumption that once a year you could bill a 99213 (25) with 11721, 11055 if you were doing a "yearly diabetic foot exam." This is not the case. Medicare has outlined when it is appropriate to do so, and expects you know the rules.

So true. So many things will be denied without a 25 modifier, but use it too often and you will be an audit risk and warned as such by CMS. It is why so many just charge an office visit for RFC, which is less audit prone, but less defensible if audited.

 

[dtrack22]

It is why so many just charge an office visit for RFC, which is less audit prone, but less defensible if audited.

If by less defensible you mean completely indefensible, then yes.

 

[malleolusman]

Find another pathology and bill for that. Edema/varicose veins/xerosis. Have a convo, recommend compression hose. Nails debrided as a courtesy.

Bill for what you do. Do what you bill for.

I’ve been doing that for older patients who don’t meet criteria. The 50 year old who had their knees replaced and wants a trim, I give them a local nail salons card. And I expect that nail salon to send ingrowns to my office.

 

[HardRoadPaved]

And I expect that nail salon to send ingrowns to my office.

Especially the ones they cause 😂

 

[king22]

If a patient comes for routine foot care and it consist of both nail debridement and cutting of the callus every 2-3 months am I able to use modifier 25?

If you intend to bill for an E&M the same visit as the routine foot care, then yes, you can.

That being said, use it only if you perform a service which qualifies for a separately reimbursed E&M service.

I'd say about 50-70% of my RFC billing also includes an E&M. I happen to deal with a relatively older patient population who often have numerous foot issues other than just their nails/calluses. I'm constantly evaluating shoe gear, modifying it, Rx steroid creams, etc.


I'm constantly sending charts to advantage plans to justify my use of 25. Pretty much once they receive the charts i get paid (I think out of 37 denials for modifier 25 last year, 34 or 33 were overturned on appeal once the chart was sent in).

The takeaway point is only use it if you can justify it. Know the rules.

 

[icebreaker32]

If by less defensible you mean completely indefensible, then yes.

You are correct. I never coded like that for RFC and I am not suggesting that others do. The first time that I learned some code this way for RFC was actually when I was a student.

 

[king22]

Just a follow up on my initial post- So I reviewed my billing last year and out of 38 denials for modifier 25, 34 were overturned on initial appeal. The remaining 4 were all claims where I used the same diagnosis for both the E&M and the procedure (in this case, B35.1). Despite what many older pods may tell you, a different diagnosis code is not "necessary" in order for a separate E&M service to be reimbursed. In fact, in the updated E&M guidelines in 2021, this point was reiterated ("The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date"). In all 4 instances, I had debrided a patient's nails and discussed/Rx Lamisil. I believed (and continue to believe) that reviewing a patient's current medication, ordering/reviewing labs (i.e. hepatic functional panel), discussing Lamisil's risks/benefits , and then Rx lamisil....counts as a separately payable 99213.

Humana and Blue Cross disagree. I haven't decided if I want to take it to the next level of appeal. My office manager says to drop it but part of me wants to continue just on principle. They're screwing me (and definitely other providers) out of rightful payment for services rendered.

 

[heybrother]

I received a letter from Cigna today indicating that they will require clinic notes for all established (9921x) encounters with a 25 modifier. I write defensible notes. My partner does not. That said, it will still generate additional work for the office.

 

[icebreaker32]

I received a letter from Cigna today indicating that they will require clinic notes for all established (9921x) encounters with a 25 modifier. I write defensible notes. My partner does not. That said, it will still generate additional work for the office.

Lots of podiatrists are getting that same letter. Starting August right?

 

[heybrother]

Lots of podiatrists are getting that same letter. Starting August right?

Its soon - I don't want to make up a date. I also received a letter indicating I'd get a new fee schedule in September. Of course it will be based on 2020 to avoid giving the 2021 E&M values.

 

[king22]

I received a letter from Cigna today indicating that they will require clinic notes for all established (9921x) encounters with a 25 modifier. I write defensible notes. My partner does not. That said, it will still generate additional work for the office.

My feeling is that this will be temporary (at least for all modifier 25 claims other than initial visit). This is like the "fungal nail" photo request in the New York area before payment for 11720/11721 back in the early 2000s. Lasted about a year until the insurers found out how much of a hassle it was to go through hundreds of thousands of photos. One major plan actually required a positive nail biopsy prior to payment. They quickly realized that this ended costing them more money hahaha

 

[Creflo]

I often bill a 25 modifier with at risk toenail and/or callus care, probably more often than most. But when I do, I take a photo of every pathology because I know it's a red flag for audit. So let's say they have erythrasma, fungal nails, and a callus. I'm taking a photo of the wood's lamp exam, the affected fungal nails, and the callus. If I can't show the e&m pathology with a photo or xray image, I shy away from the 25 mod.

 

[HardRoadPaved]

imagine if you were in gyno or proctology explaining to the patient.... sorry need a photo so I can make sure insurance believes me.

 

[Pronation]

Imagine actually being a TFP with a wood's lamp

 

[Shiyuan]

Imagine actually being a TFP with a wood's lamp

I use a handheld black light sparingly, mostly to rule out erythrasma or look at how dirty my exam rooms truly are 😜

 

[HardRoadPaved]

or look at how dirty my exam rooms truly are 😜

Hope you dont share an office with an REI specialist

 

[619]

If I can't show the e&m pathology with a photo or xray image, I shy away from the 25 mod.

I disagree with this logic. How long do you intend to keep practicing medicine if you feel someone is aways looking over your shoulder? This is not even good for mental health always worrying about when the feds will come burst through the door.

It's crazy the amount of fear the insurance company has put into us. Tough world out there.

 

[HardRoadPaved]

This is not even good for mental health always worrying about when the feds will come burst through the door.

The gyn who is taking clinical photos "for a 25" should be worried by the feds busting down the door. However now they have adequate defense... "your honor... i was doing my best to ensure I had correct documentation to substantiate my billing practices."

Johns Hopkins: Gynecologist hid camera inside pen

BALTIMORE (AP) — An employee told officials that a Johns Hopkins Hospital gynecologist accused of secretly videotaping patients wore a pen around his neck that may have been used to conceal a camera.

apnews.com

 

[UNVME2]

I disagree with this logic. How long do you intend to keep practicing medicine ifyou feel someone is aways looking over your shoulder? This is not even good for mental health always worrying about when the feds will come burst through the door.

It's crazy the amount of fear the insurance company has put into us. Tough world out there.

It is not a question of "if." CMS is keeping track of your use of 25 modifier and contracting auditors to flag those providers who are excessively using this modifier with debridement codes compared to their regional counterparts. If you are an outlier you will be audited, its a matter of time. If you lose the ability to contact medicare patients, your career might as well be over.

 

[619]

If you lose the ability to contact medicare patients, your career might as well be over.

Again I disagree. Ever heard of cash pay concierge practice?

Podiatry just like dentistry which is procedure based can do very well without insurance.

 

[Pronation]

Again I disagree. Ever heard of cash pay concierge practice?

Podiatry just like dentistry which is procedure based can do very well without insurance.

You're alone on this one. Losing medicare would absolutely cripple most pod practices.

 

[king22]

Quick related question- this is example below is always given as an example of an inappropriate modifier 25 use

"An established patient is seen in the office for debridement of mycotic nails. In the course of examining the feet prior to the procedure, Tinea Pedis is noted. Use of previously prescribed topical cream to treat the Tinea is recommended."

Now, what if the same established patient above came in for mycotic nail debridement and you noticed the tinea pedis. You Rx an antifungal cream. Would that be considered a separate E&M?

 

[dtrack22]

Even the first example seems like a justifiable established level 2 in addition to the nail debridement, in most cases. The latter seems like it can/should be an established level 3 (I’m making the assumption that this is a previously undiagnosed, uncomplicated condition).

 

[heybrother]

Quick related question- this is example below is always given as an example of an inappropriate modifier 25 use

"An established patient is seen in the office for debridement of mycotic nails. In the course of examining the feet prior to the procedure, Tinea Pedis is noted. Use of previously prescribed topical cream to treat the Tinea is recommended."

Now, what if the same established patient above came in for mycotic nail debridement and you noticed the tinea pedis. You Rx an antifungal cream. Would that be considered a separate E&M?

Historically instructing a patient to continue a prescription still counted as prescription management.

Prescription Drug Management – Meaning | Time of Care

In the level of risk for MDM, level 4 includes "Prescription drug management". But what qualifies as prescription drug management? A new Rx, Rx refill, increasing or decreasing Rx dose, discontinuing Rx, and continuing Rx all qualify as prescription drug management. Any management of...

www.timeofcare.com

E/M FAQ -- What constitutes prescription drug management?

This is posted since 2021

E/M FAQ -- What constitutes prescription drug management?​

Q. During an evaluation and management visit, what constitutes "prescription drug management?"
A. "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered "prescription drug management."

"Prescription drug management" does differ from "drug therapy requiring intensive monitoring for toxicity".
Per the CPT definitions, "drug therapy requiring intensive monitoring for toxicity" is for a drug requiring intensive monitoring which is a therapeutic agent with the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis.
Examples of monitoring that does not qualify includes monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.

 

[HardRoadPaved]

Historically instructing a patient to continue a prescription still counted as prescription management.

Prescription Drug Management – Meaning | Time of Care

In the level of risk for MDM, level 4 includes "Prescription drug management". But what qualifies as prescription drug management? A new Rx, Rx refill, increasing or decreasing Rx dose, discontinuing Rx, and continuing Rx all qualify as prescription drug management. Any management of...

www.timeofcare.com

E/M FAQ -- What constitutes prescription drug management?

This is posted since 2021

Yep this is why with the 2021 rule changes its been so easy to get to that level 4 e/m... you just need 2 of 3 categories in medical decision making also rather than all 3 with new patients in the old rules.

 

[NatCh]

Again I disagree. Ever heard of cash pay concierge practice?

Podiatry just like dentistry which is procedure based can do very well without insurance.

Oh hell, I would hate having a concierge practice. My patients are high-need enough as it is. Add 24/7 cell phone availability? Text me with random questions on the weekend? No thanks.

One of my regular referral sources is a sports chiropracter who has that type of practice. When his patients come see me they're in that same mindset. "Can I get your cell number in case I think of any questions?"

 

[king22]

Another modifier 25 question- for an established patient with a hx of ingrown toe nails presents (previous appt was several months ago) with an ingrown toe nail and a severe paronychia. You perform a nail avulsion, demarcate the erythema, and Rx an oral abx. Would it be appropriate to bill a 99213 for the paronychia and a 11730 for the ingrown toe nail?

 

[NatCh]

Another modifier 25 question- for an established patient with a hx of ingrown toe nails presents (previous appt was several months ago) with an ingrown toe nail and a severe paronychia. You perform a nail avulsion, demarcate the erythema, and Rx an oral abx. Would it be appropriate to bill a 99213 for the paronychia and a 11730 for the ingrown toe nail?

I probably would. Maybe add an A4550 for the surgical tray (if you use one) too (unless they're Medicare, in which case it's not covered).

 

[dtrack22]

I would bill the e/m with the modifier and the procedure code like the owner of my favorite OF account, said above.

 

[HardRoadPaved]

Just got a letter from Cigna:

"The modifier 25.... reimbursement policy update will not go in effect on August 13,2022, as originally scheduled. We will communicate a new implementation date and details after our internal evaluation is complete."

guess they realized the avalanche of paperwork with these automatic denials.

 

[heybrother]

Just got a letter from Cigna:

"The modifier 25.... reimbursement policy update will not go in effect on August 13,2022, as originally scheduled. We will communicate a new implementation date and details after our internal evaluation is complete."

guess they realized the avalanche of paperwork with these automatic denials.

Also received this.

 

[NatCh]

Hope you dont share an office with an REI specialist

I dunno. It could be fun for awhile...

 

[air bud]

Another modifier 25 question- for an established patient with a hx of ingrown toe nails presents (previous appt was several months ago) with an ingrown toe nail and a severe paronychia. You perform a nail avulsion, demarcate the erythema, and Rx an oral abx. Would it be appropriate to bill a 99213 for the paronychia and a 11730 for the ingrown toe nail?

We are joking here right? The ingrown nail is causing the paronychia. And how the hell do you demarcate it in your office?

 

[NatCh]

We are joking here right? The ingrown nail is causing the paronychia. And how the hell do you demarcate it in your office?

…a ballpoint pen?

 

[king22]

We are joking here right? The ingrown nail is causing the paronychia. And how the hell do you demarcate it in your office?

Well there are multiple options- Ball point pen, permanent marker, etc. I personally use a cotton tip applicator and a bottle of GV. Works really well.


As for joking- not really. The example I gave would seem to potentially occupy a grey area. Yes, the ingrown toe nail and the paronychia are related but not necessarily one in the same. In the example I gave, a severe paronychia would be considered one where the the erythema is not merely localized to the nail fold but extending proximally to the IPJ. In this scenario, simply removing the ingrown toe nail through an avulsion (and it's subsequent post-op care) will often not be enough to take care of the paronychia. This often has to be treated with oral abx.

 

[Pronation]

This just became extra podiometric

 

[air bud]

Well there are multiple options- Ball point pen, permanent marker, etc. I personally use a cotton tip applicator and a bottle of GV. Works really well.


As for joking- not really. The example I gave would seem to potentially occupy a grey area. Yes, the ingrown toe nail and the paronychia are related but not necessarily one in the same. In the example I gave, a severe paronychia would be considered one where the the erythema is not merely localized to the nail fold but extending proximally to the IPJ. In this scenario, simply removing the ingrown toe nail through an avulsion (and it's subsequent post-op care) will often not be enough to take care of the paronychia. This often has to be treated with oral abx.

they are the EXACT same thing. Cool you want to make more money, have some decency man.

Shoot while we are at it lets get our own SDN billing/coding expert @ExperiencedDPM to weigh in....something tells me I know what he will say.

 

[king22]

they are the EXACT same thing. Cool you want to make more money, have some decency man.

Shoot while we are at it lets get our own SDN billing/coding expert @ExperiencedDPM to weigh in....something tells me I know what he will say.

IF they were the exact same thing there would be no need for a separate code. The treatments for both would always be the same.

But they aren't. You can have an ingrown nail without a paronychia and you can have a paronychia without an ingrown nail. Even when they are together, removal of the offending nail border does not necessarily treat the cellulitis that it caused (as you know, paronychia in ICD 10 is defined as "Cellulitis of toe").

 

[king22]

they are the EXACT same thing. Cool you want to make more money, have some decency man.

Shoot while we are at it lets get our own SDN billing/coding expert @ExperiencedDPM to weigh in....something tells me I know what he will say.

Keep in mind, I'm not implying that EVERY case of an ingrown toe nail with paronychia results in a separately billable E&M along with a 11730. Many, if not most, don't qualify.

 

[NatCh]

they are the EXACT same thing.

no they’re not

 

[HardRoadPaved]

I like 11765 for those month long ingrowns that are all granulomatous and not "cellulitis"

 

[Creflo]

If its a new problem:

e&m for new pain in toe, cellulitis: discuss etiology, treatment options with patient. discuss that you find incurvated nail plate on exam, and attribute pain to this, so no need (or need for) for x ray. discuss prognosis, and what is likely to happen if you do or do not do treatment options, and discuss what comorbid conditions contribute to the prognosis and risks. discuss antibiotic not needed if avulsion done.

Then you list separate paragraph in plan for the partial avulsion. describe consent obtained, describe meds used to anesthetize, procedure, aftercare, follow up, dressing application, etc.

there you go, you have an e&m with 25 mod, and a separate cpt.

let the debate go on, here goes...