Modifier 25

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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

Correct Use

  • 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

Incorrect Use

  • 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

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.

Date of Service Treatment CPT/Modifier
05/02/17 Layer closure of wound of scalp 12032
05/02/17 E/M visit to verify neurological injury 99213-25

 

Incorrect Claim Example

  • Patient was seen in the office for a cardiac evaluation
  • Dr. performed an EKG
Date of Service Treatment CPT/Modifier
05/15/17 E/M visit 99213-25
05/15/17 EKG 93000

 

Resource

 

Last Updated Oct 08, 2018