surgical CPT code with modifier 25 - example of usage

Modifier 25

25 Modifier Significantly Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need 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. 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. This circumstance may be reported by adding the 25 modifier to the appropriate level of E/M service.

Medicare requires that CPT modifier 25 should only be used on claims for evaluation and management services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service. 

Medicare pays for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre and postoperative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier 25 is added to the E/M code on the claim.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

Modifier 25 Examples

Example 1: The patient sees the physician for knee pain. After examining the patient, meeting the criteria for the E/M and making the determination at the time of the visit that the patient needs a joint injection, the physician may use the 25 modifier on the office visit and be paid for the injection also.

Example 2: The physician tells the same patient in Example 1 to come back to his office in two weeks for another injection for the same complaint. He may not bill an office visit with the 25 modifier along with the joint injection. He may only bill the joint injection because this was planned prior to the visit and the criteria for an E/M service would not have been met.

Example 3: An office visit and suturing a scalp wound could be properly billed together with the use of a 25 modifier if a full neurological examination was made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status. In the circumstance when the decision to perform a minor procedure is typically done immediately before the service (e.g., whether or not sutures are needed to close a wound, whether or not to remove a mole or wart, etc.), it is considered a routine preoperative service and a visit or consultation should not be reported in addition to the procedure.

Important Modifiers with definition and when to use

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service:

The physician may need 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. 

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 day. This circumstance may be reported by adding the modifier '-25' to the appropriate level of E/M service, or the separate five digit modifier 09925 may be used. 

Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier '-57'.

The rules of 25 Modifier usage

25 Modifier

Significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

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-10 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.

The following conditions must be met to report modifier 25:

*  The patient’s condition required a significant, identifiable E/M service above and beyond the other service provided or services beyond the usual preoperative and postoperative care associated with the procedure that was performed.

*  These circumstances may be reported by adding the 25 modifier to the appropriate level of the E/M service.

1. The phrase, “the patient’s condition required” is extremely important. In other words, it was medically necessary for the patient to have these extra services on the same day that another procedure or service was performed.

2. The phrase, “a significant, separately identifiable E/M service above and beyond” the other service provided indicates that this extra service was clearly different from the other procedure or service that was performed.

3. The phrase, “services beyond the usual preoperative and postoperative care” associated with the procedure emphasizes the fact that all procedures as defined in the Resource-Based Relative Value Scale (RBRVS) system of reimbursement that Medicare uses include a certain amount of preoperative and postoperative care in the reimbursement package. 

The 25 modifier should be used if extra work beyond the usual is performed. A good standard for judging whether the 25 modifier should be used is: If a physician in the same specialty area would agree after reading the clinical record that extra preoperative and/or postoperative work beyond what is usually performed with that service was performed, then it is proper to use the 25 modifier to indicate that extra work. To document the extra work performed, the clinical record should clearly indicate that extra or unusual work.

Primary considerations for modifier 25 usages are:

 Why is the physician seeing the patient?

o If the patient exhibits symptoms from which the physician diagnoses the condition and begins treatment by performing a minor procedure or an endoscopy on that same day, modifier 25 should be added to the correct level of E/M service.

o If the patient is present for the minor procedure or endoscopy only, modifier 25 does not apply.

o If the E/M service was to familiarize the patient with the minor procedure or endoscopy immediately before the procedure, modifier 25 does not apply.

*  If the E/M service is related to the decision to perform a major procedure (90-day global), modifier 25 is not appropriate. The correct modifier is modifier 57, decision for surgery.

*  When determining the level of visit to bill when modifier 25 is used, physicians should consider only the content and time associated with the separate E/M service, not the content or time of the procedure.

Guidelines

1. Should a separately identifiable E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, information substantiating the E/M service must be clearly documented in the patient’s medical record, to justify use of the modifier –25.

2. Modifier –25 may be appended only to E/M service codes and then only for those within the range of 99201-99499. For outpatient services paid under OPPS, the relevant code ranges are:

99201-99215 (Office or Outpatient Services)

99281-99285 (Emergency Department Services)

99291 (Critical Care Services)

99241-99245 (Office or Other Outpatient Consultations)

NOTE: For the reporting of services provided by hospital outpatient departments, off-site provider departments, and provider-based entities, all references in the code descriptors to “physician” are to be disregarded.

Example: A patient reports for pulmonary function testing in the morning and then attends the hypertension clinic in the afternoon. The pulmonary function tests are reported without an E/M service code. However, an E/M service code with the modifier –25 appended should be reported to indicate that the afternoon hypertension  clinic visit was not related to the pulmonary function testing.

3. Medicare requires that modifier –25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s).

Example #1: A patient is seen in the ED with complaint of a rapid heartbeat. A 12-lead ECG is performed.

In this case, the appropriate code(s) from the following code ranges can be reported:

99281-99285 (Emergency Department Services) with a modifier –25 - 93005 (Twelve lead ECG)

Example #2: A patient is seen in the ED after a fall. Lacerations sustained from the fall are repaired and radiological x-rays are performed.

In this case, the appropriate code(s) from the following code ranges can be reported:

99281-99285 (Emergency Department Services) with a modifier –25 - 12001-13160 (Repair/Closure of the Laceration) - 70010-79900 (Radiological X-ray)

4. When the reporting of an E/M service with modifier –25 is appropriate (that is, the documentation of the service meets the requirements of the specific E/M service code), it is not necessary that the diagnosis code for which the E/M service was rendered be different than the diagnosis code for which the diagnostic

Modifier 25 Frequently Asked Questions

1. What is the definition of a “Modifier”* A modifier is a two-digit numeric or alphanumeric character reported with a HCPCS code, when appropriate. Modifiers are designed to give Medicare and commercial payers additional information needed to process a claim. This includes HCPCS Level I (Physicians’ Current Procedural Terminology [CPT®]) and HCPCS Level II codes.

2. What are the uses of Modifiers?

According to the 2015 CPT© professional Code Book, a modifier provides the means to report or indicate that a service or procedure that has been performed had been altered by some specific circumstances but not changed in its definition or code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities.

3. What is Modifier 25?

Modifier-25 is used for an unrelated evaluation and management (E/M) by the same provider or other qualified health care professional that is a significant, separately identifiable services performed on the same day as another procedure or service. 

The physician must show, by documentation in the medical record, that on the day a procedure was performed, the patient’s condition required a separately identifiable E/M service above and beyond the usual care associated with the procedure that was performed. A significant, separately identifiable E/M service is substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

4. What are some of the appropriate usages of Modifier 25?

• Use modifier 25 on an E/M service when performed at the same session as a preventive care visit when a significant, separately identifiable E/M service is performed in addition to the preventive care.

• The E/M service must be carried out for a nonpreventive clinical reason, and the ICD-9- CM code(s) for the E/M service should clearly indicate the nonpreventive nature of the E/M service.

• Attach modifier 25 to the E/M code representing a significant, separately identifiable service performed on the same day as routine foot care. The visit must be medically necessary.

• 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 pre and postoperative care associated with the procedure or service performed.

• Use Modifier 25 with the appropriate level of E/M service.

• The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File.

• An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation

supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)

• Use modifier 25 when the E/M service is separate from that required for the procedure and a clearly documented, distinct and significantly identifiable service was rendered.

• When using 25 on an E/M service on the same day as a procedure, the E/M service must have the key elements (history, examination, and medical decision making) welldocumented. NOTE: However, although CPT does not limit this modifier to use only with a specific type of procedure or service, many third-party payers will not accept modifier 25 on an E/M service when billed with a minor procedure on the same day

 5. Can you use Modifier 25 for an unexpected incident or unplanned reason?

If, during the course of the preventive medicine visit, an abnormality or preexisting problem is addressed, physicians may receive payment for that part of the visit; however, the problem should be significant enough to warrant additional work that meets the requirements of at least a problem oriented E&M visit. In this case, that part of the visit may be billed by using the appropriate office/outpatient service code with the modifier 25 (significant, separately identifiable E&M service by the same physician, same day) along with the preventive medicine code.

6. What is the most common use of Modifier 25 for EPSDT (THSteps) checkups* 

The most common use of Modifier 25 associated to a THSteps checkup is when an immunization or vaccination is administered. Modifier 25 is used to indicate that the immunization or vaccination is an E/M service that was performed at the same session as a preventive care visit.

The use of Modifier 25 appended to the claim form shows (along with documentation in the medical record) that a significant, separately identifiable E/M service was performed in addition to the checkup.

7. What are the requirements for using Modifier 25*

The use of modifier 25 has specific requirements.

• The E/M service must be significant. The problem must warrant physician work that is medically necessary. This can be defined as a problem that requires treatment with a prescription or a problem that would require the patient or family to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M-25 service.

• The E/M service must be separate. The problem must be distinct from the other E/M service provided (e.g., preventive medicine) or the procedure being completed. Separate documentation for the E/M-25 problem is helpful in supporting the use of modifier 25 and especially important to support any necessary denial appeal.

• The E/M service must be provided on the same day as the other procedure or E/M service. This may be at the same encounter or a separate encounter on the same day. • Modifier 25 should always be attached to the E/M code. If provided with a preventive medicine visit, it should be attached to the established office E/M code (99211–99215).

• The separately billed E/M service must meet documentation requirements for the code level selected. It will sometimes be based on time spent counseling and coordinating care for chronic problems.

• A comment from the child or parent turns an encounter that was scheduled as a preventive medicine visit into something more. According to CPT, separate, significant physician

evaluation and management (E/M) work that goes above and beyond the physician work normally associated with a preventive medicine service or a minor surgical procedure is additionally billable.

8. What are incorrect uses of Modifier 25*

• Using modifier 25 to report an E/M service that resulted in the decision to perform major surgery (see modifier 57).

• Billing an E/M service with modifier 25 when a physician performs ventilation management in addition to an E/M service.

• Using modifier 25 on an E/M service performed on a different day than the procedure.

• Using modifier 25 on the office visit E/M level of service code when on the same day a minor procedure (e.g., an endometrial biopsy) was performed, when the patient’s trip to the office was strictly for the minor procedure (e.g., biopsy).

9. Where should Modifier 25 be placed on the claim form*

Modifier 25 is appended to an Evaluation and Management (E&M) service (never to a procedure code) to indicate a significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of a procedure or other service was provided.

10. How do I know if the extra work is “significant” and therefore, additionally billable* 

Since CPT does not define “significant,” asking yourself the following questions should lead you to the answer:

• Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem*

• Could the complaint or problem stand alone as a billable service*

• Is there a different diagnosis for this portion of the visit*

• If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code*

Insurance’s Policy for Modifier 25

If the provider provides both a service or procedure and an evaluation and management (E&M) on the same day, it must be significant, separate, and identifiable. Documentation must support both services and show that the E&M was above and beyond the service or procedure provided.

When preventive care codes 99381-99387 or 99391-99397 are billed with office visit codes 99201-99203 or 99211-99213 (with modifier 25 on the office visit code) chart notes are not needed; both codes will be allowed. For all other preventive care & office visit code combinations (or these combinations  billed without modifier 25), chart notes are required for consideration of both codes.

When the original claim is received with both preventive services and office visit charges:

• The system will stop the claim for review to allow the adjudicator to determine if chart notes are attached to the claim.

• If there are no chart notes submitted, the charges for the medical office visit will be considered provider write-off. If notes are attached, the notes will be reviewed and, based on the content, a determination will be made whether or not the office visit is appropriate.

• Claims received as rebills with notes will be forwarded to a Claims Research Analyst.

Examples

Examples of when both charges would not be appropriate:

• A patient who has a history of hypertension is scheduled for a routine physical. You make brief mention of the hypertension and re-fill the patient’s prescription.

• During an annual gynecological exam, a patient mentions that she is having hot flashes, and you order blood work to check hormone level.

• A child is seen for a well-child checkup and you note  at he has an ear infection and prescribe antibiotics. Examples of when both charges would be appropriate:

• A patient is scheduled for a routine physical with a history of hypertension, and upon examination, you discover that the patient’s blood pressure is extremely high. The patient  says he is having lightheadedness and ringing in the ears. You take measures to reduce the blood pressure and  counsel the patient on how to monitor the condition.

• During an annual gynecological exam, you find a lump in a patient’s breast and order additional blood work and radiological procedures. You also take additional time to go over treatment options with the patient.