Reimbursement Issues Related to Modifier 25

CPT defines modifier 25 as “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.”  It indicates that the patient’s condition required an additional E/M service beyond the usual pre-operative care provided for the procedure or service.  Additional language in CPT emphasizes the importance of chart documentation.  It states, “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.”  CPT adds that “This modifier is not used to report an E/M service that resulted in a decision to perform surgery.”

This FAQ addresses the following:

  1. What does modifier 25 mean?
  2. What types of procedures or services require the use of modifier 25?
  3. Must we have more than one diagnosis on the claim to use modifier 25?
  4. If there is only one diagnosis, how do we determine when to bill the visit as well as the procedure?
  5. When is the use of modifier 25 not appropriate?
  6. Does use of modifier 25 affect the value ascribed to the exam?
  7. Will the use of modifier 25 attract attention from Medicare?
  8. What is the best way to document a minor procedure?

Two case studies are also included.

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