When is it appropriate to bill using modifier 25?
By: Teri Thurston, PECAA Billing & Coding Manager

Modifier 25 is defined as significant, separately identifiable evaluation and management (E/M) 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 indicate an evaluation and management (E/M) service or eye code was performed on the day a minor procedure (0 or 10-day global period) was also performed. The physician may need to indicate the patient’s condition required a separate and significant E/M service, above and beyond the care associated with the normal service for the procedure.

Documentation in the patient’s medical record must support the use of this modifier. 2017 CPT guideline description for this modifier specifies that a significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M
services to be reported.

A different ICD-10-CM code from the one submitted with the minor surgery is not required with the E/M code. The diagnosis for the E/M service and the other procedure may be the same or different.

This modifier may be used to indicate that an E/M service was provided on the same day as another procedure that would normally be bundled under the National Correct Coding Initiative (NCCI). In this situation, CPT modifier 25 signifies that the E/M service was performed for a reason unrelated to the other procedure.

There are situations that may not be easily defined by this criterion. In these situations, it is important to review the patient’s intent. For example, if the intent of the patient was to be seen for the procedure to be performed and the physician can proceed without an evaluation, then only the procedure is billed.

If the physician must evaluate the condition before determining a treatment option (procedure), both the evaluation and procedure are allowed.

Know when to append modifier 25 by understanding the intent of the E/M portion of the visit:

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