modifier 25, 25 modifier

Modifier 25 | Description & Billing Guidelines

The 25 modifier can be attached to an E/M code when the health provider provides the procedure on the same day as another service. Below you can find the official description and billing guidelines of modifier 25.

What Is Modifier 25?

The 25 modifier can be reported if the medical documentation justifies that an E/M service is provided on the same day as another (E/M) procedure. This can occur due to the patient’s condition and, therefore, medically necessary.

This modifier may be appended to the second E/M procedure to prove to the payer that it was a separate service from the first E/M procedure provided on the same day.

Description

Modifier 25 is officially described by the CPTs manual as: “Significant, separately identifiable evaluation and management (E/) service by the same physician or other qualified health care professional on the same day of the procedure or other service.”

Billing Guidelines

You can’t bill an E/M if you don’t have a HEM when you bill modifier 25. 

HEM Meaning: History, Exam & Medical decision making. 

The procedures include E/M services but be aware that another E/M procedure has to have its own HEM.

Modifier 25 can be billed if the physician has determined that additional work is required for performing one or more key components of the E/M service. 

This modifier can only be reported with a minimum of two codes. Do not report this modifier on claims with only one service. 

It is impossible to have a separately identifiable procedure without an accompanying initial service, according to AAPC.

Modifier 25 can be used by physicians or NPPs (Non-Physician Practitioners) to designate an E/M procedure that is separate and identifiable and performed by the same person, on the same day, on the same patient as another provided E/M service with a global fee period.

Be careful with the definition provided by CMS (See MLN Matters article MM502) because it is sometimes misunderstood by medical coders. This modifier is often unnecessary reported because many procedures do not have a global period, so this modifier can not be used.

Check the payers’ guidelines because sometimes they require modifier 25 even when the extra procedure has no global period.

How To Determine If Modifier 25 is Appropriate

To determine if modifier 25 is appropriate, you can ask the following questions according to the American Academy of Family Physicians (AAFP).

  1. Is there a different diagnosis for this portion of the visit?
  2. Are the key components of a problem-oriented E/M service performed and documented?
  3. Can the problem/complaint also be billed as a stand-alone service?
  4. Did you do extra physician work for the same diagnosis, which went beyond and above the normal post- or postoperative work of this procedure?

Go back to the complete list of CPT modifiers.


Resources

https://www.aafp.org/pubs/fpm/issues/2004/1000/p21.html

https://www.aapc.com/codes/coding-newsletters/my-cardiology-coding-alert/master-these-top-3-modifier-25-problems-and-get-claims-paid-article

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R954CP.pdf

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