CPT Modifier -25 Usage and Reimbursement

Significant, Separately Identifiable E/M Service by Same Physician on Same Day of Procedure or Other Service

Physicians and Qualified Nonphysician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.

It should be used when the E/M service is above and beyond the usual pre- and post operative work of a procedure with a global fee period performed on the same day as the E/M service.

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier -25 is added to the E/M code on the claim.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient’s medical record to support the need for Modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim.

Reimbursement

Carriers will not pay for an E/M service reported with a procedure having a global fee period unless CPT modifier -25 is appended to the E/M service to designate it as a significant and separately identifiable E/M service from the procedure. Such payment will be denied with the following messages:

Claim Adjustment Reason Code

97 - Payment is included in the allowance for another service/procedure.

Remittance Advice Remark Code

M144 - Pre-/post-operative care payment is included in the allowance for the surgery/procedure

Please note: The Centers for Medicare & Medicaid Services (CMS) has clarified the documentation requirements and policy requirements for the use of CPT modifier -25 used with E/M services. Please refer to the manual attachment to CR5025, The Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.6, for revisions regarding the use of CPT modifier - 25.

Reference: https://www.cms.gov/mlnmattersarticles/downloads/MM5025.pdf

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