Modifier 25, 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, is used when distinct services are performed on the same day. The appropriate use of modifier 25 can be a source of confusion for many medical coding professionals.
Modifier 25 Definition
Appendix A of the CPT Manual defines modifier 25 as:
25 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: 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 Service 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. The circumstances 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.
Note: For significant, separately identifiable non-E/M services, see modifier 59.
Preoperative and Postoperative Services
- E/M service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)
- Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
- Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified healthcare professionals
- Writing orders
- Evaluating the patient in the post anesthesia recovery area
- Typical postoperative follow-up care
CPT Assistant (March 2023 Page: 1-12) gives the following examples of included pre- and post-operative services typically associated with a procedure, which cannot be reported with a separate E/M services:
- Review of patient’s relevant past medical history
- Assessment of the problem area to be treated by surgical or other service
- Formulation and explanation of the clinical diagnosis
- Review and explanation of the procedure to the patient, family, or caregiver
- Discussion of alternative treatment or diagnostic options
- Obtaining informed consent
- Providing postoperative care instructions
- Discussion of any further treatment and follow up after the procedure
Multiple E/M Services
In numerous subsections of the CPT codebook, instructions can be found regarding instances where more than one E/M service is performed and reported on the same day. In these cases, the appropriate E/M code would be appended with modifier 25. For example, if in the process of performing a preventative medicine E/M service, a problem or abnormality is identified and is significant enough to require additional work to perform the key components of a problem oriented E/M service, then the appropriate Office or Other Outpatient code (99201-99215) may be reported in addition to the preventative medicine E/M service. If an insignificant or trivial problem/abnormality is encountered and does not require additional work, the E/M service should not be reported separately.
Example 1: An established patient presented to her physician’s office with a 1.5 cm laceration of her left wrist. After the physician performed a simple laceration repair, the patient asked the physician to evaluate swelling of the right ankle. An expanded, problem-focused H&P with low complexity medical decision making was performed. What code(s) should be reported?
- 12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.5 cm or less
- 99213-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making, 20-29 minutes
The evaluation of the laceration is inclusive of the preprocedural evaluation and is included in 12001. However, because the swelling of the ankle is a separately identifiable and significant problem, both the surgical procedure and the E/M service code are assigned.
Example 2: During a previous visit, the provider evaluated the patient’s right knee pain, prescribed medication and scheduled a follow-up visit two weeks later where arthrocentesis would be performed if the pain had not improved. Two weeks later (current visit), the patient’s knee pain had not resolved, and the provider performed arthrocentesis. What code(s) should be reported for the current visit?
- 20610-RT Arthrocentesis, aspiration and/or injection, major joint of bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance
In this case, the focus of the current visit was related to the performance of arthrocentesis. It would not be appropriate to report the E/M service in addition to the procedure.
Key Points for Reporting Modifier 25
- Modifier 25 should only be used with E/M codes
- Modifier 25 should only be appended to an E/M code if the service provided meets the definition of a “significant, separately identifiable” E/M procedure or other service performed on the same date, as defined by CPT
- The significantly and separately identifiable E/M service(s) provided must be properly documented in the medical record.
- Modifier 25 should not be used to report an E/M service that results in a decision to perform surgery (modifier 57 should be reported instead)
- CPT coding guidelines do not require different diagnoses for the E/M service and the additional procedure or service performed to be reported.
Additional information regarding modifier 25 can be found below:
- AMA CPT Assistant, March 2012 Page: 4-7, “Modifiers 25 and 59”
- AHA Coding Clinic for HCPCS, Third Quarter 2001 Page: 6 “Modifier -25”
- AMA CPT Assistant, March 2023 Page: 1-12 Modifier 25 reporting
- The National Correct Coding Initiative