Sunday, 15 January 2017

Modifier 25

Indicates on the day of a procedure or other service, the patient's condition required a significant, separately identifiable Evaluation and Management (E/M) service above and beyond the other service provided or beyond the usual pre-operative and post-operative care associated with the procedure that was performed. 

This modifier should only be used if an E/M is being billed on the same day as a procedure.

Correct Use

This modifier may be used to indicate that an E/M service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery.

Documentation in the patient's medical record must support the use of this modifier.

This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99321-99323 and 99341-99345. These codes are listed as new patient codes and are automatically excluded from the global surgery package. They are reimbursed separately from surgical procedure and no modifier is required.  

New patient CPT codes required CPT modifier 25 when a separately identifiable E/M service is performed the same day as chemotherapy or non-chemotherapy infusions or injections as these are not considered surgery.

No supporting documentation is required with the claim when this modifier is submitted.

A different ICD-9 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 bundle 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.

Incorrect Use

A physician other than the physician performing the procedure.

Documentation shows the amount of work performed is consistent with that normally performed with the procedure.

Claim Example

A patient was seen to close a wound due to a motor vehicle accident (12032). They also checked for any neurological injury (99212). The 12032 has a 10-day global period, so modifier 25 is appended to 99212. (Per NCCI edits, 99212 does not bundle with 12032).

Date of Service : 08/02/12
Treatment : Layer closure of wounds of scalp
CPT  99212 /Modifier 25



E/M visit – Verify neurological injury.

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