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The Modifier 25 Dilemma...

Updated: Oct 1

The use of modifier 25 always causes a slight pause from physicians and coders alike. Why is this? Is it because the narrative is confusing? Is it because there are many gray areas where a modifier could be appropriate? The answer is YES to both!


To make is easier, let's break down the Centers for Medicare Medicaid Services (CMS) guidance on the subject.


What You Need to Know

Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service.


To have additional clarity, CMS identifies the same physician as physicians in the same group practice who are of the same specialty. Think same taxonomy. This does not include providers in the group that may have a different specialty or taxonomy.


Use of a modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual service provided.


Appropriate Use

A modifier 25 is appropriate if the clinician sees a patient with what is determined a significantly, separate service. Some examples of those could be:

  • A complication

  • A new problem

  • A minor surgical procedure: E/M is performed and results in the need for the procedure (minor procedures = 0 global days)

  • A test that is required to have a modifier 25 per payer guidelines

Inappropriate use

This does not apply if the patient is scheduled for a procedure and has an E/M service provided on the same day to confirm the service can still be performed. The E/M service is considered an integral part of the procedure and cannot be reported separately.

Your documentation should clearly outline the amount of work performed is consistent with the level of effort normally performed and is not a significant, separately identifiable E/M service.


Things to Remember

  • Modifier 25 should not be reported on procedure code 99211.

  • Do not append modifier 25 to the following E/M codes that are for new patients: 92002, 92004, 99202-99205, 99341-99345


References

CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 40.2-40.5

CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 23, section 30.2

E/M Service-specific coding instructions

Frequently Asked Questions: Evaluation and management services

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