Coding Corner: How and when to append modifier 25

February 01, 2017
Area(s) of Interest: Emergency Medicine 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, and Suzan Hauptman, senior principal for ACE Med group specializing in auditing, assessments, coding, compliance, expert opinion, writing, reporting and education.  

To apply 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 correctly, you must know what distinguishes a “separate, significantly identifiable” evaluation and management (E/M) service.

Not all E/M services are billable
All billable medical procedures include an “inherent” E/M component, to gauge the patient’s overall health and the medical appropriateness of the service. For example, if a patient has a mole removed, the procedure includes general preparation such as measuring vitals, updating medications, confirming the mole location and its current state, etc.

To report a separate E/M service with modifier 25 appended, the visit must be more involved. The available documentation should describe an independent, standalone E/M service, in addition to the procedure. The encounter note could include the patient history, a listing of co-morbidities and their possible effects on the current condition, a medically-warranted examination, and documented medical decision-making (for instance, deciding that the best treatment is a procedure performed that day). If the note touches only briefly on the current issue and the need for the additional service or procedure, consider the E/M service to be part of the procedure, and not separately billable.

Typically, if the E/M service is unrelated to the minor procedure (i.e., the E/M takes place for a different concern or 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 the following questions to help determining if modifier 25 is appropriate:

  • 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?

CPT Assistant (May 2011) gives an example:

A 4-year-old slips on the edge of a pool, strikes the mandible and experienced a 3.5-cm serrated and curvilinear, full-thickness laceration of the chin. The child’s pediatrician elects to widely excise the serrated skin margins and undermine the dermis from the subcutaneous tissue to reduce the tension on the suture line. The wound is then approximated in layers with absorbable interrupted sutures and a running subcuticular closure.

This procedure would be reported 13132 Repair complex, forehead, cheeks, chin, mouth neck, axillae, genitalia, hands and/or feet; 2.6 to 7.5 cm. Any significant, separately identifiable evaluation and management service performed in addition to the wound repair would be reported separately using modifier 25.

As long as both the E/M service and the procedure are clearly documented, you don’t need separate notes (although separate notes can help).

Every service or procedure needs a diagnosis
Both the procedure and the separate, same-day E/M service must be linked to a diagnosis substantiated in the medical record. The diagnoses supporting each service may be the same, or different. Per Transmittal R954CP, “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” [emphasis added]. 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).

Append modifier 25 only to minor procedures
A minor procedure is any procedure/CPT® code with a zero- 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). You should 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 a coding 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. 


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