Modifier 25 | Separate E/M Services On The Same Day By The Same Physician Or Other

Modifier 25 can be used when a patient receives an E/M service on the same day as another service or procedure, when a provider renders two E/M services to the same patient on the same day, or when a patient’s condition warrants the same provider performing a separate E/M service and another service or procedure on the same day. However, it is important to ensure that the E/M service meets the criteria for a separate service and that the documentation justifies the use of the modifier.

1. What is modifier 25?

Modifier 25 is a CPT modifier that indicates that a significant, separately identifiable evaluation and management (E/M) service was provided by the same physician or qualified healthcare professional on the same day as another service or procedure. It is appended to the E/M service code to indicate that the service was distinct and separate from the other service or procedure provided on the same day.

2. When to use the 25 modifier?

Modifier 25 should be used when a provider renders an E/M service to a patient on the same day as another service or procedure. The medical documentation must justify performing the separate E/M service. The patient’s condition may warrant the same provider performing a separate E/M service and another service or procedure on the same day. A provider may also render two E/M services to the same patient on the same day. In such cases, modifier 25 should be appended to the second E/M service to prove that it was separate from the first E/M.

3. Description

The official definition of modifier 25 is “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”

4. Examples

Examples of procedures that require modifier 25 include a patient who visits their physician for a routine check-up and receives a flu shot during the same visit.

In this case, the physician would bill for both the E/M service and the flu shot, appending modifier 25 to the E/M service code to indicate that it was a separate service.

Another example is a patient who visits their dermatologist for a skin biopsy and receives an E/M service during the same visit. In this case, the dermatologist would bill for both the skin biopsy and the E/M service, appending modifier 25 to the E/M service code to indicate that it was a separate service.

5. Documentation

To use modifier 25, the medical documentation must justify performing the separate E/M service.

The documentation should clearly indicate that the E/M service was distinct and separate from the other service or procedure provided on the same day.

The documentation should also include the reason for the E/M service, the history of the patient’s condition, the examination performed, and the medical decision-making involved in providing the service.

6. Billing

When billing for an E/M service with modifier 25, it is important to remember that if you don’t have a history, exam, and medical decision-making (HEM), you can’t bill for an E/M service.

The physician must determine whether the problem is significant enough to require additional work to perform the key components of the problem-oriented E/M service. When submitting claims solely of an E/M code, ensure you don’t include modifier 25.

According to CMS, physicians and qualified nonphysician practitioners (NPP) should use 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.

7. Common mistakes

One common mistake medical coders make when using modifier 25 is appending it to an E/M service that does not meet the criteria for a separate service. Another mistake is failing to provide sufficient documentation to justify modifier 25.

To avoid these mistakes, coders should ensure that the E/M service meets the criteria for a separate service and that the documentation clearly justifies modifier 25.

8. Other modifiers related to modifier 25

Other modifiers related to modifier 25 include modifier 24, which indicates that an E/M service was unrelated to a surgical procedure and was performed during the global period of the surgery.

Modifier 57 indicates that an E/M service resulted in the decision to perform a major surgical procedure on the same day or the next day.

9. Tips

When using modifier 25, it is vital to ensure that the E/M service meets the criteria for a separate service and that the documentation justifies the use of the modifier.

10. Conclusion

Modifier 25 is a modifier that indicates that a significant, separately identifiable E/M service was provided by the same physician or qualified healthcare professional on the same day as another service or procedure. It is essential to use modifier 25 appropriately and ensure the documentation justifies its use.