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.
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.