When is it Appropriate to Use Modifier 25?

Here is some basic information to know about modifier 25.

Modifier 25 is defined as the modifier appended to an Evaluation and Management (E&M) service indicating that a significant and separately identifiable E&M service was provided on the same day by the same qualified practitioner as a procedure.

Modifier 25 is applied to a service not a procedure code. For example, you would not apply modifier 25 to each 99202 CPT code. However, if you saw a new patient, completed the services rendered as appropriate to bill a 99202 E&M, and performed an injection on the same day, you would apply a 25 modifier on the new patient E&M service.

Do not make the mistake many providers do in presuming the need to apply a 25 modifier to all evaluation and management procedures that you bill.

The most common errors in relation to modifier 25 are not applying the modifier when it is necessary, overusing it when it is not necessary, and the inappropriate use of this modifier on procedural service codes.

The definition of the modifier 25 denotes the E&M service to be significant and separately identifiable.

The provider performing the service must accurately show the criteria were met within their patient’s medical record. Significance can be determined by the level of service provided and time

spent on the E&M with your patient. Separately distinguishable requires a procedure be performed in addition to the E&M service on the same day that was not mandated by the evaluation and management itself.

Per CMS guidelines, both the medically necessary E/M service and the performed procedure must be substantiated by the physician or qualified NPP in the patient’s medical record to support the need for the Modifier 25 on the claim. The documentation is not required to be submitted with the claim, but it could be subsequently requested by the patient’s insurance. For this reason alone, document, document, document.

Almost all providers bill for the evaluation and management services of new patients. Choose the proper E&M service code by determining your patient’s status on the date of service, new or established, the place of service the E&M is performed in, and the level of the service provided to your patient.

Proper use of modifier 25 comes into play with both new and established patient E&M services. An established patient E&M service is applicable with a newly presented diagnosis. The procedure performed can substantiate the need for an evaluation and management of your patient. In either determination, the 25 modifier is only applicable when in addition to a procedure performed the same day by the same qualified practitioner.

Remember, separately identifiable is the key. If your services to the patient did not include a procedure outside of the completed evaluation and management, you would NOT apply the modifier 25 to the E&M CPT on your insurance claim. The modifier 25 will NEVER be used on any reporting codes, procedures or any services other than E&M services. However, it is not to be mistakenly used on EVERY evaluation and management procedure you bill.