Know When to Use Modifier 25 With a Minor Procedure
Question: I often see providers performing minor procedures (like lesion removals or joint injections) and also documenting an evaluation and management (E/M) visit on the same day. They frequently ask me to add modifier 25 to get payment for both services. Sometimes, the diagnosis codes are the same for both the procedure and the E/M. I’ve also heard different advice: Some say we always need separate diagnoses and others say we need separate documentation. Can you clarify when it’s appropriate to report an E/M with modifier 25 on the same day as a minor procedure? Nebraska Subscriber Answer: This is a common area of confusion, and your caution is well-placed. Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) should be appended to an E/M service only when that service is significant and separately identifiable from the minor procedure or service provided on the same day by the same physician or qualified provider. Minor procedures with a 0- or 10-day global period already include a basic E/M component. This means a brief assessment to confirm the need for the procedure is already factored into the procedure’s payment and should not be billed separately. Modifier 25 is appropriate when the provider performs additional evaluation or management that goes beyond the usual pre-service work required for the procedure. You do not need different diagnosis codes to report modifier 25. While a different diagnosis may help demonstrate that the E/M is unrelated, the deciding factor is the documentation. If the E/M service is for the same condition but includes work that is above and beyond what’s typical for the procedure — for example, managing a change in the patient’s condition or addressing a separate concern — it may still be reported separately. You also do not need physically separate documentation, but clearly distinguishing the E/M from the procedure in the note can help support the claim. What matters most is that the documentation shows that the provider performed medically necessary, additional work that is not bundled into the minor procedure. For example, if a provider evaluates a patient for knee pain and performs a joint injection for osteoarthritis, and the E/M visit was only provided to decide whether to perform the injection, you should not report the E/M separately. However, if the provider also evaluated unrelated back pain or managed a separate condition during the same visit, and this work is documented, then it may be appropriate to report the E/M with modifier 25. In summary, use modifier 25 only when the E/M is truly separate and significant. Diagnosis codes may be the same or different, but documentation must support the claim. Always ensure the physician’s note clearly justifies the additional service beyond what’s included with the procedure. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
