Modifier 25 Appropriate Use

Modifier 25 indicates a “significant, separately identifiable evaluation & management (E&M) service by the same physician on the same day of the procedure or other therapeutic service.”

  • Both services rendered must be significant, separate and distinct
  • Medicare will not make separate payment unless the documentation supports significantly, separately identifiable service that is not routinely provided in preforming the service.
  • The visit should stand alone as a medically necessary billable service.
  • Documentation must be in the medical record to fully support both the visit and the procedure.

Examples of Appropriate Use

Ex: 1.) Patient presents with a skin lesion and has a history of melanoma. The provider preforms the excision and then does a full body examination for other concerning lesions based on the patients past personal history of melanoma.

Rationale: Due to the risk to the patient with the personal history of the melanoma requires the physician to obtain a history and perform an extensive exam that was above and beyond what was necessary for the procedure.

Ex: 2.) A 45-year-old male visited his family physician for his annual check-up. The physician performed and documented a comprehensive review of systems along with his medical, family, and social history. A comprehensive multisystem examination was performed. Counseling on diet, exercise, and prevention was provided, and appropriate laboratory tests were ordered. During the encounter, the patient complained of bilateral knee pain with tenderness and swelling. The physician found during the examination that both knees were swollen. Additional history was obtained, the knees were further examined, and the patient was then given a prescription for a nonsteroidal anti-inflammatory drug and was asked to return in two weeks.

Rationale: the provider addressed and acute condition that required active treatment, extra work in obtaining history, evaluation of the knee, and treatment above and beyond what was included in the routine preventive service.

Key Considerations in Determining Whether to Append Modifier 25 to an E/M

  • Was the physician’s evaluation and management of the problem significant and beyond the normal preoperative and postoperative work? If yes, then an E/M service may be reported with modifier 25 If not, it is not appropriate to report an E/M service with modifier 25 appended, as the service is included as part of the surgical package.
  • Was the procedure or service scheduled before the patient encounter? If yes, then it would not be medically necessary to report an E/M service unless the patient had other concerns or problems that were addressed during the same encounter.