Back to Basics: Modifier-25

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.” (Holden, K. 2021).

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When Assigning Modifier-25 Here are Some Key Points to Follow:

1. Modifier-25 may be appended to an evaluation and management (E&M) CPT® code only to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. (99202-99215, 99281-99285, 99291, 99241-99245)

2. Modifier-25 may be appended when the patient’s problem requires 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.

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Example: A 54-year-old established patient presented to the primary care provider’s office for follow-up of long-standing hypertension. During the visit, the patient mentioned right wrist pain that began one month prior. The patient had been working remotely due to the COVID-19 pandemic without an ergonomically correct workstation. The treatment plan included changes in the hypertensive medication from Hydrochlorothiazide to Lisinopril. Wrist x-rays were performed and reviewed, brace support was provided, and a discussion of a steroid joint injection for carpal tunnel syndrome. The patient asked if it would be possible to have the injection today. A 25-gauge needle was used to enter the carpal tunnel. 1 mL of triamcinolone was injected after aspiration. The medications flowed freely without any difficulty. After the procedure, the patient clenched and unclenched the fingers of both hands for a period of two minutes to distribute the medication. There were no complications.

In this case, an E&M level and modifier-25 are both assigned as this scenario meets the criteria for “the E/M service being above and beyond the other service provided”. The reason for the office visit was for follow-up of long-standing hypertension. The patient mentioned right wrist pain during the visit and an injection was performed.

3. Modifier-25 may be appended to a significant and separate E&M service substantiated by the documentation that meets the criteria for reporting the E&M service on the same date of service.

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Example: A morbidly obese patient presented to the pulmonologist’s office with COPD for a pulmonary function test to assess lung capacity. Spirometry with bronchodilation was performed. Later that day, the patient presented to the hypertensive clinic to discuss long-standing hypertension.

In this case, CPT® code 94060 would be assigned for the pulmonary function test encounter. The E&M level (99212-99215) with modifier- 25 would be assigned for the hypertensive clinic visit. These services were unrelated; therefore modifier-25 may be appended.

4. Modifier-25 may be appended when the E&M service or services are related to the same or different diagnosis as the other procedure(s).

Centers for Medicare Services further defined, “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.”

5. Modifier-25 may be appended when the E&M services are provided in conjunction with another reportable service assigned with a CPT ®or HCPCS code.

Note: always append modifier- 25 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). (CMS 2000, p. 1).

Example: A patient presented to the ED with a spasm in their abdominal wall muscles. An EMG was performed with a single needle on the left side of the abdomen.

In this case, the E/M level (99281-99285) with modifier-25 and CPT® code 95870 for EMG of the abdominal wall would be assigned.

Medicare Global Surgery Rules prevent the reporting of a separate E&M service that resulted in the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.

6. Do not assign modifier-25 to the E&M service that resulted in the decision to perform surgery.

Note: Modifier -57 would be assigned to the E&M service that resulted in the decision to perform major surgery with a 090-day global period. (CMS 2018, p. 6).

7. Do not assign modifier -25 to the E&M for minor surgical and endoscopies procedure(s) with a global period 000-010 days.

Do not assign any E&M level for the work-up of the minor surgery as the pre-procedure, intra-procedure, and post-procedure work as inherent in the procedure. (CMS 2021, p. 21)

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References:

Holden, K. (Ed.). (2021) 2021 Current Procedural Coding Expert. (p.603) Optum360.

Centers for Medicare & Medicaid Services. GENERAL CORRECT CODING POLICIES FOR NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES (2021, November). https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal112021.pdf

Centers for Medicare & Medicaid Services. (2018 September.) Global Surgical Booklet.

Centers for Medicare & Medicaid Services. (2000 July.) Department of Health and Human Services (DHHS) Intermediaries HEALTH CARE FINANCING ADMINISTRATION (HCFA) Program Memorandum. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/dwnlds/a0040pdf