4 “Must Haves” to Append Modifier 25

4 “Must Haves” to Append Modifier 25

by John Verhovshek, MA, CPC

To append modifier 25 with confidence, your claim must meet four criteria.

Evaluation and Management – CEMC

1. The same provider must provide an E/M service and another procedure or separate for the same patient on the same day. All providers who bill under the same National Provider Number (such as those physicians who share an NPI in group practice) are, from a coding perspective, the “same” provider.

2. The E/M service must be significant and separately identifiable. MLN Matters Number: MM5025 states that you should apply modifier 25 only for “a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work for the service.” Generally speaking, a significant, separately identifiable E/M service might occur on the same day as another procedure or service when:

  • The provider sees a new patient, or
  • The provider sees an established patient with a new complaint or a change in status

In either case, a separate E/M service is essential to determine the need for any same-day procedure(s) or service(s) that follow. If the provider sees the patient for a previously scheduled procedure or service, you would not normally report a separate, same-day E/M service.

Providers can help to substantiate a separate E/M service by physically separating the documentation for the E/M service from documentation for any other same-day procedure(s) or service(s).

3. The E/M service doesn’t occur during the global period of a previous procedure. Related, follow-up examinations by the same provider during the global period of a previous procedure are included in that procedure’s global surgical package.

For an unrelated E/M service during the global period of a previous procedure, you may be able to report an appropriate evaluation and management code with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) appended. This would require that the E/M service is for a new problem not connected to the patient’s previous complaint or procedure.

4. The procedure(s) or service(s) on the same day does not have a 90-day global period. Append modifier 57 Decision for surgery (not 25) to a separately identifiable E/M service that occurs on the same day, or on the day before, a major surgical procedure, and which results in the physician’s decision to perform the surgery. A major surgical procedure is any procedure or service with a 90-day global period.

A final note: You do not need a separate diagnosis to justify a same-day E/M service with modifier 25. The CPT® codebook states, “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.”

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

2 Responses to “4 “Must Haves” to Append Modifier 25”

  1. Mary says:

    Actually, just being a new patient does not automatically qualify the E&M for the 25 modifier. Desicions to perform minor procedures made immediately before the procedure are included as routine preoperative services. There are times when you use the 25 modifier and times when you don’t. It really depends on multiple factors.

  2. Marilyn Bailey says:

    Work in a orthopedic surgeon office and when patient comes in and has a cast applied and EM visit the service is billed with a mod 25 on EM. Now the visit is getting denied stating that it is in post op care. Is there a new mod for this? We are charging for the cast and material. Also if the doctor is doing a cortisone injection it is the same. PLEASE HELP.

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