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Appropriate Use of Modifier 25

The Current Procedural Terminology (CPT) definition of modifier 25 is as follows:


Modifier 25 – this modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician.  The American Medical Association (AMA) Current Procedural Terminology (CPT) book defines Modifier 25 as a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.  A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service).  The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.  As such, different diagnoses are not required for reporting of the E/M services on the same date.  This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.  Note:  This modifier is not used to report an E/M service that resulted in a decision to perform surgery.  See modifier 57.  For significant, separately identifiable non-E/M services, see modifier 59.

There are several nationally recognized sources of information on modifier 25.  The Centers of Medicare and Medicaid Services (CMS) requires that modifier 25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service.

Here is an example of an appropriate use of modifier 25:

Example 1:  A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise.  The patient has a history of hypertension and high cholesterol.  After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed that day by the same physician.

Coding for Example 1:  The physician codes an E/M visit (99201 – 99215) and he also codes for the cardiovascular stress test (93015).  The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure. 
 Coding example:  99214, 25
                           93015

99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components.

93015 - Cardiovascular stress test

The modifier stops the bundling of the E/M visit into the procedure. When reviewing the physician’s documentation the carrier should be able to determine that both the E/M and the procedure were medically necessary.  As always, the documentation has to support the claim that your office sends to the carrier.
 

When Not to Use the Modifier 25

  1. Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery. 
  2. Do not append modifier 25 if there is only an E/M service performed during the office visit (no procedure done).
  3. Do not use a modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed.  
  4. Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable.  All procedures have “inherent” E/M service included.  See example #2.
  5. Patient came in for a scheduled procedure only

 

Example 2:  When a patient is scheduled to come into your office for a cardiovascular stress test and the physician also completes a history and performs a limited examination (specifically related for the stress test) your office should only code for the cardiovascular stress test (93015).
Coding Example:  93015


A Few Rules to Remember When Using the Modifier 25  

  1. Modifiers are needed to inform third-party payers of circumstances that may affect the way payment is made – the modifiers tell a story of what is actually being done!  
  2. Always link the modifier to the E/M CPT code
  3. It is not necessary to have two different diagnosis codes
  4. Need to document both the E/M and document the procedure

 

Per the NCCI general correct coding policies, modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of 000 or 010 days) or procedures not covered by global surgery rules (global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient with the decision to perform surgery the same or next day.

One Last Note

When you submit a claim to the insurance carrier that is coded with a 25 modifier, you are telling the carrier to pay you for both the E/M visit and the minor procedure.  The carrier will (in most cases) pay you for both the E/M visit and the minor procedure.  Often in the past claims with both an E/M and procedure have been reviewed for accuracy.  When you bill both codes on the same day will your documentation support both codes?  Will you have documented a history, exam and medical decision making (or two of three key elements, depending on your E/M code) separate from the procedure?  Typically when these services have been audited payment was rescinded due to incorrect coding, incomplete documentation, and/or lack of medical necessity to support both codes billed on the same day by the same physician.

Modifier 25 can be used for outpatient, inpatient, and ambulatory surgery centers hospital outpatient use.

Modifier 25 can be used in other situations such as with critical care codes and emergency department visits.

Please reference the 2011 AMA CPT coding book for full definition of the codes.

For further information on level of service please see the CMS E/M coding guidelines for ’95 and ’97 at the websites listed below.


References

  1. AMA CPT 2012 Coding Book
  2. AMA Principles of CPT Coding
  3. Evaluation and Management Services Guide
  4. CMS Manual
  5. NCCI (National Correct Coding Initiative)
  6. OIG (Office of Inspector General
  7. 1995 Documentation and Guidelines for Evaluation & Management Services

 

For further information email your questions to coding@acc.org

CPT Copyright 2010 American Medical Association.  All rights reserved.

 

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