Wound Care Articles and Insights

Wound Care Billing & Coding: Proceed with Caution When Using E&M and Modifier 25

Wound Care Billing & Coding: Proceed with Caution When Using E&M and Modifier 25

Wound care physicians and clinicians, take note! 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.

In the wound clinic, a typical patient visit involves examination and assessment, cleansing and debridement, and removal and reapplication of wound dressings. If the physician performs a “significant, separately identifiable service,” it can be documented on the patient’s record as an E&M service with modifier 25. However, the service must be performed for a condition or issue that is not related to the scheduled office visit, and it must be a new condition that requires further evaluation and treatment.


We strongly recommend using modifier 25 on an extremely limited basis, if at all. It’s only appropriate in about 10 percent of cases and can be seen by auditors as “double dipping.”


Here are a few examples where using modifier 25 is appropriate:


Example 1:

The patient presents for his weekly appointment to treat a diabetic foot ulcer. It is noted that he has a significant cough and a 103-degree fever. The physician suspects bronchitis or pneumonia, examines the patient, and orders lab tests. In this case, it would be appropriate to use modifier 25 because a distinctly different condition is being treated.


Example 2:

A wound care patient presents for her first of 20 hyperbaric oxygen therapy treatment sessions for post-radiation therapy injuries. The patient is also a diabetic. She tells the technician about a wound on her lower leg that is unrelated to the post-radiation injury. The technician alerts the wound care physician, who is also supervising the HBO therapy. The physician evaluates the wound immediately following the HBOT session and treats it. In this case, modifier 25 is needed on the E&M because treatment for the leg wound is separate from the physician supervision for the radiation injury. One service is for HBOT supervision of the radiation injury, and the other is for wound care of the lower leg.


Example 3:

A patient is being treated for a diabetic foot ulcer. After several weeks of treatment, she presents for her appointment and tells the physician she has pain in her sacral area. A pressure ulcer is discovered, most likely from long periods of sitting with her leg elevated. But because the pressure ulcer is an etiology that has never been addressed before, the use of modifier 25 is justified in this case.


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.


If you’d like more information or need assistance with wound care program operations, please contact us at 888-484-3922.