Modifier 25

Indicates on the day of a procedure or other service, the patient's condition required a significant, separately identifiable Evaluation and Management (E&M) service above and beyond the other service provided or beyond the usual pre-operative and post-operative care associated with the procedure that was performed. This modifier should only be used if an E&M is being billed on the same day as a procedure.

Correct Use

  • May be appended to indicate that an E&M service or eye exam, which is performed on same day as a minor surgery (0 or 10 global days) and which is performed by a surgeon, is significant and separately identifiable from usual work associated with the surgery
  • Documentation in patient's medical record must support use of this modifier
  • Same rule applies when reporting services to new patients; E&M visit must be significant and separately identifiable from work associated with the surgery; however, new patient E&M codes are excluded from 25 modifier prepayment edits and should not be reported
  • New patient CPT codes requires this modifier when a separately identifiable E&M service is performed same day as chemotherapy or non-chemotherapy infusions or injections as these are not considered surgery
  • No supporting documentation is required with claim when this modifier is submitted
  • A different ICD-9 or 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
  • May be used 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 procedure

Incorrect Use

  • A physician other than physician performing procedure rendered E&M service
  • Documentation shows amount of work performed is consistent with that normally performed with procedure

Example

A patient was seen to close a wound due to a motor vehicle accident (12032). They also checked for any neurological injury (99212). Since 12032 has a 10-day global period, modifier 25 was appended to 99212. (Per NCCI edits, 99212 does not bundle with 12032).

Date of Service Treatment CPT/Modifier
08/02/14 Layer closure of wounds of scalp 12032
08/02/14 E/M visit – Verify neurological injury 99212 25


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Last Updated Fri, 28 Feb 2020 13:04:24 +0000