The CPT coding system was introduced in 1966, and was originally intended to simplify documenting procedures that physicians performed. By 1970, the system had changed to include lab procedures, and the codes had expanded to five digits. The concept of modifiers was introduced in the third edition of CPT in 1973.
Modifiers provide additional information about a procedure is without actually changing its definition. Modifiers are always two characters with most being numeric, though there are some alphanumeric modifier.
Many coders have difficulty in knowing when/how to use Modifier 25, and it is hoped that the following information will assist in enhancing understanding and, therefore, proper use of this modifier.
Modifier 25 is only valid when it is used on/with an E/M procedure code. It is NOT valid if it is appended to surgical CPT codes; medicine procedures; or diagnostic tests and procedures. Should this modifier be used with codes for any of these, the line item will be denied as an invalid modifier combination.
Medicare requires that Modifier 25 be used only on claims for E/M services, and only when the E/M service is provided by the same physician on the same day as a global procedure or service. In addition to these requirements, payment will only be made if the physician indicates that service is for a significant, separate E/M service that is above and beyond any usual preoperative and postoperative work required on the day of the procedure. The physician is obliged to thoroughly document both the medical necessity of the E/M service in addition to documenting the procedure itself in (not surprisingly) the patient’s medical record. While the documentation requirements are clear, the documentation itself does not have to be submitted with the claim.
The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services has this to say about Modifier 25:
- The “CPT Manual” defines modifier 25 as a “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.” Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).
The AMA’s CPT code book states that modifiers provide a means to report/show that a service or procedure that has been performed has been altered due to certain circumstances, but not changed in the actual definition or code. It goes on to say this specifically about Modifier 25, stating it is a:
- Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same day of the Procedure or Other Service.
Modifier 25 is a meaningful coding tool for physicians who bill for E/M services allowing them to show the patient’s condition required a significant, separately identifiable E/M service also be performed that was above and beyond the original service that was originally anticipated and performed. An easier way to explain this would be that Modifier 25 conveys that the physician provided an exam that met the definition of a service that the exam was significantly different than any other service provided that day.
There are many, many websites that provide additional information and examples of the proper use of Modifier 25. See the attached references for further information. Also attached are some tips on using Modifier 25 along with several examples of correctly/incorrectly used Modifier 25.
REFERENCES and ADDITIONAL INFORMATION:
- https://www.modahealth.com/pdfs/reimburse/RPM028.pdf
- https://www.palmettogba.com/palmetto/jmb.nsf/DIDC/8EELF54813~Claims~Modifier%20Lookup
- https://www.cms.gov/Medicare/Coding/NCCI-Coding-Edits
- https://www.carecloud.com/continuum/modifier-59-25-91-guide-coders/
- https://www.acc.org/tools-and-practice-support/practice-solutions/coding-and-reimbursement/appropriate-use-of-modifier-25
- https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912 Chapter 12, Section 40.2–40.5
- https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c23.pdf Chapter 23, Addendum at the end of the chapter
Further Information on the Use of Modifier -25 in Reporting Hospital Outpatient Services https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/CMS-Program-Memoranda-Items/CMS052227
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MODIFIER 25* |
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APPROPRIATE USE OF MODIFIER 25 |
Modifier 25 should be used to inform third party payers of circumstances that could affect the payment that is being made; the modifier adds additional information to the story of what has been done. |
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Always link Modifier 25 to the specific E/M CPT code and NOT the procedure code. |
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When using Modifier 25, remember that two different diagnosis codes are not necessary. |
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Documentation of both the E/M service and procedure code is required; remember to document the medical necessity. |
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Submission of a claim with Modifier 25 tells the insurance carrier that you’re expecting to be paid for both the E/M visit and the minor procedure. |
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Modifier 25 can be used for outpatient, inpatient, and ambulatory surgery centers. |
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Modifier 25 can be used in other situations such as with critical care codes and ED visits. |
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INAPPROPRIATE USE OF MODIFIER 25 |
Do not use Modifier 25 when billing for services performed during a postoperative period if related to the pervious surgery |
| Do not use Modifier 25 if there is only an E/M service performed during an office visit and no procedure has been performed | |
| Do not use Modifier 25 with any E/M service on the day a major (90 day global) procedure is performed. | |
| Do not use Modifier 25 if a minimal procedure is performed on the same day in addition to an E/M service UNLESS documentation of the level of service shows it is significant and separately identifiable. CPT assumes all same procedures have an “inherent” E/M service built in to the service’s definition. | |
| Do not use Modifier 25 if the patient only came in for a scheduled procedure. | |
*This chart is not intended to be all-inclusive. It just offers some examples on the proper and/or improper use of Modifier 25.
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EXAMPLES OF USING MODIFIER 25 |
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CORRECTLY USED |
History: DOS – 1-3-22
CPT code: 20610- LT – Knee joint injection (0 global days) E/M code: 99214-25 (Established patient office visit; 30-39 minutes) Patient with osteoarthritis left knee was scheduled for an injection into the knee. Prior medical treatments – oral meds and joint injections – had failed. Further evaluation (additional assessment and intervention) was performed by the physician and a TKR of the left knee is planned. Outcome: Modifier 25 is used with the code for the evaluation and planned major surgery to treat the patient’s arthritis. |
| History: DOS – 2-15-22
CPT Code: 20553 – Trigger point injections (0 global days) E/M code: 99213-25 (Established patient office visit: 20-29 minutes) Patient was evaluated for treatment of neck pain and elevated BP. Trigger point injections were administered for the neck pain. New prescription was written to control the increased HTN. Outcome: Submit Modifier 25 with the visit for the evaluation and treatment of the elevated blood pressure. |
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INCORRECTLY USED |
History: DOS – 1-24-22
CPT code: 11042 – Debridement skin & subcutaneous tissue (0 global days) E/M code: 99213-25 (Established patient office visit: 20 – 29 minutes) E/M code 99213-25 was submitted to reflect the physician’s time, exam, and decision making related to the need for skin debridement. However, the physician’s time was not significant, nor was it separately identifiable from the usual effort associated with the surgery. No other conditions were addressed during the encounter. Outcome: The E/M service should NOT have been submitted because it is not separately reimbursable from the surgical procedure itself. Only the surgical procedure CPT code (11042) should be submitted |
