Modifier 25: Appropriate Use
Modifier 25 Basics
Modifier 25 Definition: Significant, separately identifiable Evaluation and Management (E/M) by the same physician or other qualified health care professional on the same day of the procedure or other service. Let’s break the definition down:
Significant: In order to support an E/M code, the work must be significant. This can be defined as a problem that requires considerable workup or treatment or a problem that, if not addressed at today’s visit, would require the patient to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M service in addition to a procedure.
Separately identifiable: The documentation needs to support the elements of an E/M service that are over and above what a provider would perform pre-operatively for the procedure that day. While it isn’t required to document the E/M visit separately from the pre-op work, the documentation should clearly support the work that was performed to support a separate E/M visit.
Same physician: Medicare defines the same physician as physicians in the same group practice who are of the same specialty. In this instance, they must bill and be paid as though they were a single physician.
- Indicates on day of a procedure or other service identified patient’s condition required a significant, separately identifiable E/M service above and beyond other service provided or beyond usual pre-operative and post-operative care associated with procedure that was performed
- Use to indicate that an E/M service or eye exam, performed on same day as a minor surgery (000 or 010 global days) and performed by surgeon, is significant and separately identifiable from usual work associated with surgery
- New patient CPT codes are required when a separately identifiable E/M service is performed same day as chemotherapy or non-chemotherapy infusion or injections as these are not considered surgery
- A different ICD-10 code from one submitted with minor surgery is not required with E/M code. Diagnosis for E/M service and other procedure may be same or different
- Use to indicate that an E/M service was provided on same day as another procedure that would normally bundle under National Correct Coding Initiative (NCCI). In this situation, this modifier signifies that E/M service was performed for a reason unrelated to other procedures
- To bill for an E/M service, must have a history, exam and medical decision making (HEM). All procedures include some service related to patient evaluation and management. A separate E/M should include its own HEM. Physician must determine whether problem is significant enough to require additional work to perform key components of problem-oriented E/M service
- Do not append to E/M codes that are explicitly for new patient only (CPTs 92002, 92004, 99201-99205, 99321-99323 and 99341-99345). These codes are listed as new patient codes and are automatically excluded from global surgery package edit. They are reimbursed separately from surgical procedure and no modifier is required if visit meets significant and separately identifiable guidelines
- A physician other than physician performing procedure
- Do not use when documentation shows amount of work performed is consistent with that normally performed with procedure
- Do not use if it is billed with a procedure or service with a no global fee period
A few rules to remember when using Modifier 25:
- Modifiers are needed to inform third-party payers of circumstances that may affect the way payment is made – the modifiers tell a story of what is actually being done!
- Always link the modifier to the E/M CPT code
- It is not necessary to have two different diagnosis codes
- Need to document both the E/M and the procedure
Correct Claim Example
A patient was in a motor vehicle accident and was seen to close a wound (CPT 12032). Physician checked for any neurological injury (CPT 99213). CPT 12032 has a 10-day global period, modifier 25 is appended to CPT 99213. Per NCCI edits, CPT 12032 and 99213 is listed with an indicator 1 with rationale edit saying CPT manual or CMS manual coding instructions. Documentation in the patient’s medical record must support the use of this modifier. Supporting documentation is not required with the submitted claim.
When Not to Use the Modifier 25
- Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery.
- Do not append modifier 25 if there is only an E/M service performed during the office visit (no procedure done).
- Do not use a modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed.
- Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have an “inherent” E/M service included.
- The patient came in for a scheduled procedure only
Modifiers © Copyright 2021 American Medical Association
Understanding the correct and appropriate use of modifier 25 will be key to filing correct claims, which will then result in correct payment. Not only does the 25 modifier allow us to code physician services to the highest level of specificity possible, but it ensures the physician is paid accordingly for those services. Still not sure about the appropriate use of Modifier 25? Don’t worry E2E Medical Billing Services has an experienced coding team that uses exact modifiers to avoid denials. To know more about our medical billing services call us at 888-552-1290 or write to us at [email protected]