modifier 25, 25 modifier

Modifier 25 | Description, Uses, Guidelines & Examples (2023)

Modifier 25 applies when the physician performs a significantly different or Separately Identifiable Evaluation and Management procedure by the Same Physician or Other skilled Professional on the exact procedure date or Other Service.

Description Of Modifier 25

Modifier 25 can be used when the physician performs a significantly different or separately identifiable evaluation and management procedure by the same physician or another skilled professional on the exact procedure date or another service.

The official description of the 25 modifier 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.”

Modifier 25 plays a significant role in the payment of Evaluation and Management services. It pays for the physician’s benefits with the highest accuracy level and confirms the physician’s payment according to the physician’s efforts. If the claim fills accurately with the appropriate modifier leads to the proper and early reimbursement.

It depends upon the circumstances which modifier is appropriate. For example, 57 applies to evaluation and management service instead of 25 when the physician performs Evaluation and Management service and decides to perform the surgery on the same day. However, if the physician performs other than the Evaluation and management service, it is appropriate to report modifier 59 if needed.

Modifier 25 only appropriates when the physician provides the Evaluation and management service on the same day as a diagnostic or therapeutic procedure. Similarly, If no other surgical, diagnostic, or therapeutic procedure performs in combination with the E/M visit code, then 25 is not applicable. 

It is not significant that Modifier 25 is applicable when the same physician performs the Evaluation and the management service. However, the physician can be different if the provider furnishes significantly identifiable service combined with the surgical, diagnostic, or therapeutic procedure.

If the emergency department service performs (99281-99285) in combination with the surgical, diagnostic, or therapeutic procedure, It is appropriate to append 25 with Emergency department services.

Modifier 25 does not require a different diagnosis code for both E/M CPT codes and diagnostic procedures as long as they meet the definition of significant, separately identifiable service. If the service does not meet the 25, it may deny by the insurance carrier or third party. 

25 modifier

What Is Modifier 25?

Modifier 25 applies when the same physician performs specific services on the same day and in conjunction with the same patient’s other services. It may be compulsory to attach with the service or procedure to indicate the separately identified service on the same date on the same patient by the Same Physician.

The significantly identifiable service should be a more effective E/M than the other performed on the same day or require more attention than usual preoperative and postoperative care. 

When To Use Modifier 25

Modifier 25 is only applicable with Evaluation and Management (E/M) CPT codes 99202-99499, and It is not appropriate to report with CPT codes ranging from 10000 to 60000 in addition to anesthesia procedure codes.

Modifier 25 indicates the service performed separately from other services and reimbursement procedures. In addition, it describes that the service is medically necessary and appropriate.

If modifier 25 attach to the evaluation and management CPT codes, it is appropriate to document both E/M service and the procedure.

If the physician furnishes the service during the postoperative period and is unrelated to surgery or procedure, it is inappropriate to report E/M with modifier 25.

If only Evaluation and Management services perform in a day with no other procedure, it is inappropriate to report E/M with 25.

If the procedure has a 90-day global period, reporting E/M with modifier 25 for a related condition is inappropriate.

If the patient comes to the physician for a scheduled procedure only, Reporting the E/M code is inappropriate to report separately.

How To Use The 25 Modifier

Suppose a significantly identifiable E/M service performs the diagnostic or therapeutic procedure on the same day. In that case, documentation must reflect the need for that service in the medical records. Therefore, it is appropriate to report E/M service with modifier 25.

Modifier 25 applies to the Evaluation and Management CPT codes (99201-99499). The CPT codes divide into the sub-categories such as critical care services (99291, 99292), Emergency Department service (99281-99285), etc.

If the emergency department service (99291-99285) provides diagnostic and/or therapeutic procedures, reporting the CPT codes 99281-99285 with modifier 25 is appropriate.

Suppose the physician takes the patient’s blood pressure, consent, and temperature, asking how they feel included in the diagnostic and therapeutic procedure. In that case, Reporting E/M codes for these services is not appropriate.

If the Evaluation and management service report with modifier 25, documentation must support the medical necessity of the service. It is not significant that the same diagnosis code reports with both Evaluation and management and diagnostic, therapeutic, and surgical procedures. 

Modifier 25 vs. 59

Modifier 25 applies with Evaluation and management codes (99202-99499) only and indicates the service is a significantly identifiable service performed by the same physician on the same day. 

In contrast, Modifier 59 indicates the service is distinctly other than the evaluation management CPT codes (99202-99499) on the same day by the same physician. It reports when typically two services are not allowed to bill together on the same day. Documentation should support that the service is medically appropriate and distinct.

Modifier 24 vs. 25

Modifier 24 applies with evaluation and management CPT codes (99201-99499) when the physician provides care for an unrelated condition in the postoperative period. Documentation should support the medical necessity of service unrelated to the surgery.

In contrast, Modifier 25 evaluates and manages CPT codes (99201-99499) when the same physician performs significant service and is separately identifiable on the same day to the same patient.

99213 Modifier 25

The patient receives one or more evaluations, management visits, and surgical procedures on the same day. If E/M visits are significantly separate identifiable and medically necessary, It is appropriate to report CPT code 99213 with modifier 25 in combination with the other procedure.

If CPT 99213 performs in combination with the Emergency department (99281-99285), it is appropriate to report CPT 99213 without modifier 25. The documentation should establish the medical necessity of the service. 

If CPT 99213 performs in combination with Hospital observation (99217-99220 [99224, 99225, 99226]), it is appropriate to report CPT 99213 without modifier 25. The documentation should establish the medical necessity of the service. 

If CPT 99213 performs in combination with Hospital observation or inpatient with same-day admission and discharge (99234-99236), it is appropriate to report CPT 99213 without modifier 25. The documentation should establish the medical necessity of the service. 

99214 Modifier 25

The patient receives one or more evaluations, management visits, and surgical procedures on the same day. If E/M visits are significantly separate identifiable, and medically necessary, It is appropriate to report CPT code 99214 with modifier 25 in combination with the other procedure.

If CPT 99214 performs with the Emergency department (99281-99285), it is appropriate to report CPT 99214 without 25 Modifier. The documentation should establish the medical necessity of the service. 

If CPT 99213 performs in combination with Hospital observation (99217-99220 [99224, 99225, 99226]), it is appropriate to report CPT 99214 without modifier 25. The documentation should establish the medical necessity of the service. 

If CPT 99214 performs in combination with Hospital observation or inpatient with same-day admission and discharge (99234-99236), it is appropriate to report CPT 99214 without 25. The documentation should establish the medical necessity of the service. 

Using CPT 99283 With Modifier 25

The patient receives one or more evaluations, management visits, and surgical procedures on the same day. If E/M visits are significantly separate identifiable and medically necessary, It is appropriate to report CPT code 99283 with modifier 25 in combination with the other procedure.

If CPT 99283 performs in combination with Hospital observation (99217-99220 [99224, 99225, 99226]), it is appropriate to report only Hospital observation (99217-99220 [99224, 99225, 99226]) because of the higher payment and modifier 25 is not allowed. The documentation should support the medical necessity of the service.

How To Use CPT Code 99284 With Modifier 25

The patient receives one or more evaluations, management visits, and surgical procedures on the same day. If E/M visits are significantly separate identifiable and medically necessary, Reporting CPT code 99284 with 25 in combination with the other procedure is appropriate.

If CPT 99284 performs in combination with Hospital observation (99217-99220 [99224, 99225, 99226]), it is appropriate to report only Hospital observation (99217-99220 [99224, 99225, 99226]) because of the higher payment and modifier 25 is allowed. The documentation should establish the medical necessity of the service.

If CPT 99284 performs with critical care services (99291, 99292), Only CPT 99291 and 99292 bills because of the higher payment, and 25 is not allowed. The documentation should establish the medical necessity of the service.

Can I Use G0439 With Modifier 25?

The patient receives an annual wellness visit, one or more evaluations, and management visits. If E/M visits are significant, identifiable, and medically necessary, It is appropriate to report CPT codes 99201-99215 with 25 Modifier and Annual wellness code G0439.

How To Use Modifier 25 With A Diagnostic Test

The patient receives one or more evaluations, management visits, and diagnostic tests or therapeutic procedures on the same day. If E/M visits are significantly separate identifiable, and medically necessary, It is appropriate to report CPT code 99201-99499 with modifier 25 and the diagnostic test.

Modifier 25 With A Preventive Visit

The patient receives one or more evaluations, and management visits a preventive visit on the same day. If E/M visits are significantly separate identifiable and medically necessary, It is appropriate to report CPT code 99201-99499 with 25 combined with the preventive visits.

How To Use CPT 99203 With The 25 Modifier

The patient receives one or more evaluations, management visits, and surgical procedures on the same day. If E/M visits are significantly separate identifiable, and medically necessary, Reporting CPT code 99203 with 25 in combination with the other procedure is appropriate.

If CPT 99203 performs with the Emergency department (99281-99285), it is appropriate to report CPT 99203 without modifier 25. The documentation should establish the medical necessity of the service. 

If CPT 99203 performs in combination with Hospital observation (99217-99220 [99224, 99225, 99226]), it is appropriate to report CPT 99203 without modifier 25. The documentation should establish the medical necessity of the service.

If CPT 99203 performs in combination with Hospital observation or inpatient with same-day admission and discharge (99234-99236), it is appropriate to report CPT 99203 without 25. The documentation should establish the medical necessity of the service. 

Can I Use CPT code 99291 And 99292 With Modifier 25?

Yes, if the patient receives one or more evaluations, management visits, and surgical procedures on the same day. If E/M visits are significantly separate identifiable and medically necessary, Reporting CPT code 99291 with 25 in combination with the other procedure is appropriate.

The following are the conditions when 25 is appropriate to report with CPT 99291 and 99292:

  • If castric intubation (43752-43753) performs in combination with critical care services (99291, 99292), Attaching modifier 25 with 99291 and 99292 is appropriate.
  • If transcutaneous pacing, temporary (92953), performs in combination with critical care services (99291, 99292), Attaching 25 with 99291 and 99292 is appropriate.
  • If venous access and arterial puncture (36000, 36410, 36415, 36591, 36600) perform in combination with critical care services (99291, 99292), Attaching 25 with 99291 and 99292 is appropriate.
  • If ventilation assistance and management include CPAP and CNP (94002-94004, 94660, 94662) performs in combination with critical care services (99291, 99292), It is appropriate to attach 25 with 99291 and 99292.
  • If measuring cardiac output (93598) performed in combination with critical care services (99291, 99292), attaching modifier 25 with 99291 and 99292 is appropriate.
  • If pulse oximetry (94760-94762) performs with critical care services (99291, 99292), attaching 25 with 99291 and 99292 is appropriate.

Billing Examples

Below is an example of a case when modifier 25 can be billed appropriately.

A 36-year-old male presents to the office for a Tangential skin biopsy and has an office visit for routine hypertension and Diabetes maintenance. Suppose CPT code 99214 and 17000 bills for these services. Then, according to 25 definition, If service 99214 is significantly identifiable, it is appropriate to report an E/M visit (99202-99499) with 25.

Modifier 25 is only allowed for an office visit when this service is a significant, separately identifiable service in addition to Procedure 17000 on the same day. It requires separate time and efforts made by the physician. 

25 Modifier appends with CPT code 99214 to unbundle the service with CPT code 11102. Therefore, it may bill 99214 as the primary procedure code with 25 and 17000 as the secondary procedure code. 

Documentation must support the medical necessity of these two CPT 11102 and 99214 services on the same day for accurate reimbursement by the insurance or third-party payer.

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