In my opinion the CPT description of the modifier is written policy. Depending on the payer they probably have reference to modifier 25 in their guidelines too. This is probably one of the easiest provider coding questions to find a written answer to. Good Luck! These are Medicare examples:
E. How should modifier 25 be reported under the NCCI?
Modifier 25 may be appended to an Evaluation & Management (E&M) code when reported with another procedure or other service, on the same day of service to indicate a "significant and separately identifiable" E&M service when appropriate. For additional information, please see the NCCI Policy Manual, Chapter 1, Section E. available on the
CMS NCCI webpage.
30.6.6 - Payment for Evaluation and Management Services Provided During Global Period of Surgery
B. CPT Modifier “-25” - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. A/B MACs (B) pay 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 post-operative 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 nonphysician 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. If the physician bills the service with the CPT modifier “-25,” A/B MACs (B) pay for the service in addition to the global fee without any other requirement for documentation unless one of the following conditions is met: • When inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure; • When preoperative critical care codes are being billed on the date of the procedure, the diagnosis must support that the service is unrelated to the performance of the procedure; or • When an A/B MAC (B) has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier “-25” compared to other physicians, has done a case-by-case review of the records to verify that the use of modifier was inappropriate, and has educated the individual or group, the A/B MAC (B) may impose prepayment screens or documentation requirements for that provider or group. When a A/B MAC (B) has completed a review and determined that a high usage rate of modifier “-57,” the A/B MAC (B) must complete a case-by-case review of the records. Based upon this review, the A/B MAC (B) will educate providers regarding the appropriate use of modifier “-57.” If high usage rates continue, the A/B MAC (B) may impose prepayment screens or documentation requirements for that provider or group. A/B MACs (B) may not permit the use of CPT modifier “-25” to generate payment for multiple evaluation and management services on the same day by the same physician, notwithstanding the CPT definition of the modifier
