Modifier 25 is one of the most valuable and most scrutinized modifiers in medical billing. Used correctly, it lets you get paid for an evaluation and management (E/M) service and a procedure on the same day. Used incorrectly, it leads to denials, recoupments and audit risk.
What modifier 25 means
Modifier 25 is appended to an E/M code to indicate a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day as a procedure or other service.
The key words are significant and separately identifiable. The E/M must go beyond the usual evaluation that is already included in the procedure.
What's already included in a procedure
Procedures with a 0- or 10-day global period include the routine evaluation before the procedure: reviewing the problem, examining the area and deciding to perform the procedure. For these minor procedures, CMS states that the decision to perform the procedure is part of the procedure itself and is not separately billable. (For major surgery with a 90-day global period, the decision for surgery made the day before or the day of surgery is reported with modifier 57, not 25.)
When modifier 25 is appropriate
Example 1: a new problem during a scheduled procedure. A patient comes in for a scheduled removal of a skin lesion. During the visit, she also mentions worsening knee pain. The provider takes a history, examines the knee, orders an X-ray and starts treatment. The knee evaluation is a separate problem, so an E/M with modifier 25 can be billed along with the lesion removal.
Example 2: a preventive visit and a problem visit. During an annual wellness or preventive exam, the provider also evaluates and manages a significant new or worsening problem, such as uncontrolled blood pressure that requires a medication change. The problem-oriented E/M can be reported with modifier 25 in addition to the preventive service, when the documentation supports it.
Example 3: an evaluation that goes beyond the procedure. A patient with diabetes comes in for a planned injection, and the provider also reviews glucose logs, adjusts insulin and addresses a new foot wound. That additional management is separately identifiable.
When modifier 25 is not appropriate
- The visit was only for the procedure. A patient returns for a scheduled injection and nothing else is addressed.
- The evaluation only led to the decision to do a minor procedure. A patient presents with a laceration, the provider examines it and repairs it. The evaluation is part of the repair.
- It is added automatically. Appending modifier 25 to every E/M billed with a procedure is a red flag for payers and auditors.
Documentation tips
- Document the E/M and the procedure clearly enough that a reviewer can see two distinct services. Separate sections or headings help.
- Show the additional history, exam or medical decision making beyond the pre-procedure evaluation.
- A different diagnosis is not required by CPT, but it often makes the separate service easier to support.
- Choose the E/M level based only on the separately identifiable work, not the work included in the procedure.
The bottom line
Ask one question before using modifier 25: "If the procedure hadn't been done today, would this visit still have been necessary and documented as its own E/M?" If the answer is yes, and your documentation shows it, the modifier is likely supported. If you'd like an audit of how your providers use modifiers, our certified medical coding team can review a sample of your claims.
