Modifier 51

Modifier 25 Description, Uses, Guidelines & Examples (2022)

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.

Modifier 25 Description

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.

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 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 service 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 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, it is inappropriate to report E/M with modifier 25 for a related condition.

If the patient comes to the physician for a scheduled procedure only, Reporting the E/M code is not appropriate to report separately.

Modifier 25 Guidelines

Suppose a significantly identifiable E/M service performs with the diagnostic and 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 Emergency department service (99291-99285) provides along with diagnostic and or therapeutic procedures, it is appropriate to report the CPT codes 99281-99285 with modifier 25.

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, It is not appropriate to report E/M codes for these services.

If 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 significant 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 codes 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 in combination 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. 

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.

CPT Code 99284 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 99284 with 25 in combination with the other procedure.

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 in combination 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.

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.

Modifier 25 With A Diagnostic Test

The patient receives one or more evaluations, management visits, and the diagnostic test and or therapeutic procedure 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.

99203 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 99203 with 25 in combination with the other procedure.

If CPT 99203 performs in combination 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. 

99291 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 99291 with 25 in combination with the other procedure.

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

If Gastric intubation (43752-43753) performs in combination with critical care services (99291, 99292), It is appropriate to attach modifier 25 with 99291 and 99292.

If Transcutaneous pacing, temporary (92953), performs in combination with critical care services (99291, 99292), It is appropriate to attach 25 with 99291 and 99292.

If Venous access and arterial puncture (36000, 36410, 36415, 36591, 36600) performs in combination with critical care services (99291, 99292), It is appropriate to attach 25 with 99291 and 99292.

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 Measurement of cardiac output (93598) performs in combination with critical care services (99291, 99292), It is appropriate to attach modifier 25 with 99291 and 99292.

If Pulse oximetry (94760-94762) performs in combination with critical care services (99291, 99292), It is appropriate to attach 25 with 99291 and 99292.

Modifier 25 Examples

The following are the examples of when modifier 25 appends with the CPT codes:

Example 1

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 the 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.

Example 2

A 46-year-old male presents to the physician for laparoscopic liver tumor ablation and has an emergency department visit for Abdominal pain, Nausea with vomiting. Suppose CPT codes 47370 and 99284 bills for these services. Then, according to 25, If service 99284 is significantly identifiable, it is appropriate to report an E/M visit 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 99284 to unbundle the service with the CPT code 11102. Therefore, it may bill 99284 as the primary procedure code with 25 and 17000 as the secondary procedure code. 

Documentation must support the medical necessity of these CPT codes 99284 and 11102 on the same day for accurate reimbursement by the insurance or third-party payer.

Example 3

A 76-year-old male presents to the physician for – Combined right and left heart catheterization and has an ED visit for Angina Pectoris. Suppose CPT codes 93453 and 99284 bills for these services. Then, according to 25 definition, If service 99284 is significantly identifiable, it is appropriate to report an E/M visit (99202-99499) with 25.

25 Modifier is only allowed for office visits when this service is a significant separately identifiable service in addition to Procedure 93453 on the same day. It requires separate time and efforts made by the physician. 

Modifier 25 appends with CPT code 99284 to unbundle the service with CPT code 93453. Therefore, it may bill 99284 as the primary procedure code with 25 and 93453 as the secondary procedure code. 

Documentation must support the medical necessity of these two CPT codes, 99284 and 93454, on the same day for accurate reimbursement by the insurance or third-party payer.

Example 4

A 56-year-old male presents to the physician for a Paring or cutting of benign hyperkeratotic lesion follow-up visit for a right foot infection. Suppose CPT codes 11055 and 99213 bills for these services. Then, according to 25 definition, If service 99202 is significantly identifiable, it is appropriate to report an E/M visit (99202-99499) with 25.

25 Modifier is only allowed for an office visit when this service is a significant separately identifiable service in addition to Procedure 11055 on the same day. It requires separate time and efforts made by the physician. 

Modifier 25 appends with CPT code 99213 to unbundle the service with the CPT code 11055. Therefore, it may bill 99213 as the primary procedure code with 25 and 17000 as the secondary procedure code. 

Documentation must support the medical necessity of these two CPT codes, 99213 and 11055, on the same day for accurate reimbursement by the insurance or third-party payer.

Example 5

A 76-year-old male presents to the physician with the Destruction of a localized lesion of the retina and has an office visit for Occular pain. Suppose CPT codes 67210 and 99213 bills for these services. Then, according to 25 Modifier definition, If service 99213 is significantly identifiable, it is appropriate to report an E/M visit (99202-99499) with 25.

25 is only allowed for an office visit when this service is significantly separately identifiable in addition to Procedure 67210 on the same day. In addition, it requires separate time and efforts made by the physician. 

Modifier 25 appends with CPT code 99213 to unbundle the service with Modifier the CPT code 67210. Therefore, it may bill 99213 as the primary procedure code with 25 and 67210 as the secondary procedure code. 

Documentation must support the medical necessity of these two CPT codes, 67210 and 99213, on the same day for accurate reimbursement by the insurance or third-party payer.

Example 6

A 76-year-old male presents to the Physician – Arthroscopy of the shoulder with rotator cuff repair and has an office visit osteoarthritis of the right shoulder. Suppose CPT codes 29827 and 99203 bills for these services. Then, according to 25 definition, If service 99203 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 29827 on the same day. It requires separate time and efforts made by the physician. 

25 Modifier appends with CPT code 99203 to unbundle the service with CPT code 29827. Therefore, it may bill 99203 as the primary procedure code with 25 and 29827 as the secondary procedure code. 

Documentation must support the medical necessity of these CPT codes 29827 and 99203 on the same day for accurate reimbursement by the insurance or third-party payer.

Example 7

A 48-year-old male presents to the physician Cardiovascular stress test and has an ED visit with Chest pain. Suppose CPT codes 93015 and 99284 bills for these services. Then, according to 25 definition, If service 99284 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 93015 on the same day. It requires separate time and efforts made by the physician. 

25 Modifier appends with CPT code 99284 to unbundle the service with the CPT code 11102. It would be billed 99284 as the primary procedure code with 25 and 93015 as the secondary procedure code. 

Documentation must support the medical necessity of these two CPT codes, 99284 and 11102, on the same day for accurate reimbursement by the insurance or third-party payer.

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