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Are you using coding modifier 25?

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What is modifier 25?

Using modifier 25 signifies a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of a procedure or other service.” This modifier may be used only with E/M visit codes within the following code ranges, as long as the procedure meets the definition of “significant, separately identifiable E/M service”:

  • 92002-92014
  • 99202-99285

When can modifier 25 be used?

It may be necessary to indicate that on the day a procedure or service was performed (identified by a CPT code) and the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the criteria for the separate E/M service to be reported.  The Alliance recommends following the coding guidelines located in the AMA certified CPT coding books to select the appropriate level of E/M services.

Can modifier 25 be used during a preventative exam?

Yes, however it is uncommon.

Preventative exams are comprehensive visits that include age, gender, history, exam, counseling, anticipatory guidance, risk factor reduction interventions, ordering of labs, vaccines and diagnostic procedures. Addressing insignificant or trivial problem(s) or abnormality(s) that come up during the preventative exam should not be reported with an E/M service code (i.e., a regular office visit).

For addressing extensive abnormalities or preexisting conditions during a preventative exam may warrant the use of the modifier 25 if the problem or abnormality is significant enough to require additional work to perform key components of a problem-oriented evaluation and management service; see definitions below.

Definitions:

  • Problem – a problem is a disease, condition, illness, injury, symptom, complaint or finding.
  • Addressed problem – a problem that is addressed or managed by evaluation and/or treatment during the encounter.

Key Takeaways:

Reporting of a separate E/M service with modifier 25 must include thorough documentation with the additional components of the E/M service using the below documentation guidelines:

  • Medically appropriate history and examination.
  • Medical decision-making lossis
    • Medical decision-making elements.
      • Number and complexity of problems addressed.
      • Amount of data reviewed and analyzed.
      • Risk of complications.
    • Time
      • Total time on the date of the encounter.
      • Includes face-to-face and non-face-to-face time personally spent by physician.

Things to ask before using modifier 25:

  • What is the purpose of the encounter?
  • Any additional work-ups that are unrelated to the procedure being performed?
  • Was the work-up above and beyond that of the initial procedure?
  • Was a new treatment plan started?
  • Was there a new treated diagnosis/ addressed problem?

For additional questions on the appropriate use of modifier 25, contact Tera Mendoza, Coding Resource Specialist at [email protected].