What Is the 25 Modifier and How Do You Use It?
Navigate medical billing complexities with CPT Modifier 25. Learn to properly identify and bill for distinct services on a single day.
The CPT Modifier 25 is used in medical billing to report an Evaluation and Management (E/M) service performed on the same day as another procedure or service by the same healthcare professional. It signals that the E/M service was significant and separately identifiable from the other service, ensuring proper reimbursement for both distinct services during a single patient encounter.
What the 25 Modifier Signifies
The E/M service must be “significant,” meaning it involved substantial work, such as a detailed history, examination, and complex medical decision-making. It must also be “separately identifiable,” addressing a different problem or aspect of the same problem than the procedure. This modifier applies when the E/M service goes beyond the typical pre-operative and post-operative care included in a minor surgical procedure or other non-E/M service.
Every procedure has an inherent E/M component, covering the usual pre-service, intra-service, and post-service work. For Modifier 25 to be appropriate, the E/M service must exceed this routine work. For instance, if a patient is scheduled for a stress test, and the physician performs a limited examination specifically for that test, only the stress test should be billed, as the E/M is not separately identifiable. However, if the E/M addresses a new or exacerbated condition requiring additional medical decision-making, it may warrant Modifier 25.
When to Use the 25 Modifier
Modifier 25 applies when an E/M service is distinct from a procedure performed on the same day. The E/M service requires its own medical necessity and documentation, separate from the procedure’s inherent work. The E/M service may be prompted by the same symptom or condition for which the procedure was performed, but it must involve additional, separately identifiable work.
For example, if a patient presents with new, severe abdominal pain, and during the same visit, a laceration unrelated to the pain is repaired, the E/M service for the abdominal pain would be significant and separately identifiable from the laceration repair. Another instance involves a patient seen for a follow-up of a chronic condition, like glaucoma, during which a new, unrelated problem, such as trichiasis, is identified and addressed with a minor procedure. The E/M service for the glaucoma follow-up is distinct from the evaluation and procedure for the trichiasis, justifying Modifier 25. Similarly, if an E/M service is performed to evaluate a condition, such as an ingrown toenail, and that evaluation leads to the decision to perform the removal procedure on the same day, Modifier 25 can be appropriate if the E/M work significantly exceeds the usual pre-procedure assessment. This ensures that both the diagnostic and procedural work are recognized for reimbursement.
When Not to Use the 25 Modifier
The 25 modifier should not be used when the Evaluation and Management (E/M) service is simply part of the routine pre- or post-procedure work. Every procedure code includes an allowance for the typical E/M work involved, such as obtaining consent or providing basic pre-operative instructions. Attaching Modifier 25 in such instances would be considered unbundling.
For example, if a patient’s sole purpose for the visit is to have a previously planned minor procedure, and the E/M service performed is limited to confirming consent and preparing for that procedure, Modifier 25 is not appropriate. Routine follow-up care that falls within the global surgical package of a previously performed procedure should not be billed with Modifier 25, as this care is already included in the initial procedure’s reimbursement. Furthermore, Modifier 25 is not applied when the E/M service is the direct reason for a minor procedure, and the E/M work does not extend beyond what is inherently part of that procedure. For instance, if a mole is evaluated and then removed during the same visit, and the evaluation was solely to determine the need for removal, only the excision procedure should be billed. Modifier 25 is also specifically for services performed by the same physician or qualified healthcare professional on the same day; if services are rendered by different providers or on different dates, other modifiers would apply.
Documentation Requirements for the 25 Modifier
Proper documentation is crucial to support the use of Modifier 25. The medical record should be robust enough to justify the E/M service as if it were a standalone encounter. Specific elements that should be documented include a distinct chief complaint and a comprehensive history relevant to the E/M service.
A separate physical examination pertinent to the E/M service, beyond what is typically required for the procedure, must also be recorded. Independent medical decision-making related to the E/M service, distinct from the decision to perform the procedure, needs to be evident. While not always required, using separate diagnoses for the E/M and the procedure can further clarify the distinct nature of the services. The medical record should delineate the work performed for the E/M service from the work performed for the procedure, even if they occur within the same visit.