Coding with modifiers, part 2: Modifier 25 made easy

May 26th, 2017 / By Kimberly Crear, CPC, CEMC, AAPC Fellow

The Centers for Medicare and Medicaid Services (CMS) recognizes the use of modifier 25 with Evaluation and Management (E/M) services.

Purpose of Modifiers

Modifiers explain changes about a service without changing the actual fundamental performance details covered in the CPT or HCPCS code descriptions.

Modifier 25

Modifier 25 is defined as a “Significant 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 appended to an E/M code to identify an encounter progressing “over and beyond” the other service provided or beyond the usual pre/post-operative care associated with a performed procedure. Documentation must support medical necessity of the E/M service.

Documentation

The extra work must be evident. The provider’s documentation should be thorough and readily identifiable to sufficiently support the additional service. The E/M service is required to have an additional history, exam, assessment of work performance, benefits and/or risk that is “over and beyond” the normal requirement for the procedure.

The Diagnosis Code using Modifier 25

A different diagnosis code is not required with the use of modifier 25. The diagnosis can be the same, or it can be different.

Examples:

  • If the E/M service is prompted by a symptom/illness in which the procedure or service is provided, a different diagnosis is not required.
  • If the physician is performing an unrelated E/M service on the same day as a minor procedure, the diagnosis may be different.

Guidelines

  • Modifier 25 is only used on codes for E/M services.
  • Use modifier 25 when a significant, separately identifiable E/M service is rendered on the same day as a minor procedure (0 – 10 global period).
       – The service must be significant and separately identifiable.
  • Modifier 25 is appropriate when the E/M service provided and the minor procedure performed are rendered on the same date of service.
       – Do not report modifier 25 if an E/M service is provided and, during that visit, a minor procedure is scheduled on the subsequent day.
  • All payers will not identify or accept modifier 25.
  • Modifiers do not guarantee claims payment.
  • All modifiers will not increase payments.
  • CMS utilizes resource-based relative value units (RBRVS) and references from the National Correct Coding Initiative (NCCI).
  • Modifiers provide an explanation to insurance companies that something is different about the CPT/HCPCS codes submitted on a claim form.
  • All payers do not use the CPT’s American Medical Association (AMA) Guidelines while verifying the use of Modifier 25. Some insurance companies develop and use payer specific policies.
  • An insurance company may request provider documentation/reports to show support for billed services reflected on the claim.

Note

An E/M service that is provided on the same day as a minor procedure is included with payment for that procedure. Medicare only makes separate payments if an exception applies (i.e. also performing a significant, separately identifiable service). Various payers bundle the services, combining the E/M service with the minor procedure.

Kimberly Crear is a consultant with 3M Health Information Systems.


References

AMA CPT Manual. 2017

Medicare Claims Processing Manual. Chapter 12. Section 40.1