Coding Corner: Modifier 25: Getting it right

April 01, 2018
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

When applied properly, modifier 25 allows separate payment for an evaluation and management (E/M) service provided on the same day as a minor procedure or other reported health care service. However, modifier 25 is frequently misused, in two primary ways. 


1. Modifier 25 is appended to the E/M service code when reporting only an E/M service.


Overusing modifier 25 in this way doesn’t result in improper payments, but is still incorrect coding. You never need to append modifier 25 to an E/M service code if it is the only service reported on a claim.


For example, a physician sees an established, 5-year-old patient with tympanotomy tubes in the office for evaluation of an acutely draining ear. CPT® Appendix C (Clinical Examples) suggests this visit would likely meet the requirements to report 99213. If the E/M is the only service billed, you’d report it without any modifiers.


2. Modifier 25 is appended to an E/M service code, reported on the same claim with a procedure or other medical service, but documentation does not (or cannot) substantiate that the E/M service was significant and separately identifiable.


Coding errors of this type are more serious—because they result in “unbundling” and improper payments—and are also more difficult to correct.


Every procedure includes typical E/M services


Health care providers may argue that every procedure necessarily involves patient evaluation and management. The American Medical Association (which maintains the CPT® code set) and the Centers for Medicare and Medicaid Services agree, but the typical E/M associated with a procedure is included in the valuation for that procedure. Per CPT Assistant (Vol. 8, Issue 9, Sep. 1998), “Evaluation and management (E/M) services that are necessary for the performance of a medical procedure (for example, assessing the site/condition of the problem area, explaining the procedure, and obtaining informed consent) are included in Medicare payments for the procedure.”


In other words, just because you evaluated the patient prior to a procedure doesn’t mean you can report (and be paid for) a separate E/M service.


But, if the patient evaluation or management goes beyond that typically performed as part of a procedure, and documentation supports the separate, significant nature of the service, you may report, and receive reimbursement for, an independent E/M service.


The U.S. Department of Health and Human Services Office of Inspector General’s “Use of Modifier 25” explains:


…if a provider performs an E/M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure, the provider may attach modifier 25 to the E/M service claim to facilitate billing and to allow separate payment for the E/M service.


The Bulletin of the American College of Surgeons (Dec. 1, 2016), citing Chapter 12 of the Medicare Claims Processing Manual, elaborates:


Medicare requires that modifier 25 be used only on claims for E/M services and only when the E/M service is provided by the same physician on the same day as a global procedure or service. In addition, payment is made only if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual preoperative and postoperative work required on the day of the procedure. The physician must appropriately and sufficiently document both the medically necessary E/M service and the procedure in the patient’s medical record to support the claim for these services, even though the documentation is not required to submit with the claim.


To report a separate E/M service with modifier 25 appended, the available documentation should describe an independent, stand-alone E/M service, in addition to the procedure. Ask yourself: If I were to delete from the visit note all documentation referencing the procedure, would the remaining documentation support a medically necessary, separate E/M visit, including a chief complaint, a relevant history and exam, and medical decision-making with an assessment and treatment plan?


If not, you shouldn’t code for a separate E/M service (with or without a modifier). For example, a patient presents for a pre-scheduled EKG to be done by nursing staff. The nurse checks the patient’s medication list, inquiries about his general health, takes his blood pressure and pulse ox, connects him to the EKG, runs the strip, unhooks him from the EKG, and releases him. In this case, the E/M provided is inherent to the EKG, is neither significant nor separately identifiable, and should not be reported in addition to the EKG.


Generally, if an E/M service is unrelated to the procedure (i.e., the E/M takes place for a different concern/complaint), the E/M service may be reported separately. Additionally, if the E/M service occurs due to exacerbation of an existing condition, or another change in the patient’s status, that service may be reported separately if it is independently supported by documentation. The American Academy of Family Physicians recommends that physicians ask themselves:


  • Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?
  • Could the complaint or problem stand alone as a billable service?
  • Is there a different diagnosis for this portion of the visit?
  • If the diagnosis is the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

If the answer to all of the above is yes, it is appropriate to report a separate E/M service with modifier 25 appended.


The Bulletin of the American College of Surgeons (Dec. 1, 2016) further advises, “If you perform an E/M service above and beyond the pre-service time associated with the procedure, make sure that the extended E/M work is medically necessary; don’t evaluate other body areas or organ systems unless a good clinical rationale for doing so can be provided.”


You don’t need separate notes for the procedure and the E/M service (although it would help), but as previously stated, the documentation must support a stand-alone E/M service, with all the required elements.


Both the E/M service and the procedure must be linked to an appropriate ICD-10 diagnosis code to establish medical necessity. The diagnoses for the procedure and E/M service may be the same, or different. For example, the E/M visit may be prompted by a complaint unrelated to the same day procedure (different diagnoses), or the procedure could be for a condition that was evaluated during the visit, or for a chronic condition that would benefit from the additional service (same diagnoses). CMS Transmittal R954CP verifies, “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.”


The Bulletin of the American College of Surgeons (Dec. 1, 2016) provides an example:


…a patient who has been treated in the past for gastroesophageal reflux disease (GERD) and is scheduled to have an upper endoscopy now complains of exacerbation of known irritable bowel syndrome (IBS) and asks that you review the medications for this condition. The upper endoscopy is performed for the workup of GERD and the medications for IBS are adjusted. The work associated with the E/M related to IBS would be reported with the E/M code and modifier 25 appended to indicate this is a separate service.

Lastly, append modifier 25 to an E/M service only when provided on the same day as a minor procedure. A minor procedure is any procedure/CPT® code with a 0- or 10-day global period, as defined by Medicare’s Physician Fee Schedule Relative Value File. Examples include many injections, minor integumentary repairs and endoscopic procedures (e.g., diagnostic colonoscopy). Turn to modifier 57 Decision for surgery (rather than modifier 25) to report a separately identifiable E/M service that occurs on the same day, or on the day before, a major surgical procedure (a procedure or service with a 90-day global period), and that results in the physician’s decision to perform the surgery, according to the Medicare Claims Processing Manual, section 40.2.


CPT Assistant (March 2015) provides an example:


A patient is seen in the emergency room with acute appendicitis. The surgeon sees the patient, makes a diagnosis, and reaches a decision to perform surgery. The patient then promptly undergoes a laparoscopic appendectomy.

How to Code
Report CPT code 99222 (or similar initial emergency department code) with modifier 57, along with the appropriate appendectomy code: 99222-57 and 44970.

For more information on modifier 57, visit AAPC’s Knowledge Center at www.aapc.com/blog


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