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).

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.

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.

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)

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