Modifier 25 Primer: Use It, Don't Abuse It

Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) is the most important modifier for pediatricians in Current Procedural Terminology (CPT®). It creates the opportunity to capture physician work done when separate E/M services are provided at the time of another E/M visit or procedural service. This allows for more efficient use of your time and may save the patient another visit. However, use of this modifier has been associated with frustration because many payers, including Medicaid, do not recognize it or reduce payment as a result.

The use of modifier 25 has specific requirements. 

1. The E/M service must be significant and medically necessary. This can be defined as a problem that requires treatment with a prescription or a problem that would require the patient or family to return for another visit to address it. A minor/trivial problem or concern would not warrant the billing of an E/M 25 service.
2. The E/M service must be separate. The problem must be distinct from the other E/M service provided (eg, preventive medicine) or the procedure being completed. Separate documentation for the E/M 25 problem is helpful in supporting the use of modifier 25 and especially important to support any necessary denial appeal.
3. The E/M service must be provided on the same day as the other procedure or E/M service. This may be at the same encounter or a separate encounter on the same day.
4. Modifier 25 should always be attached to the E/M code. If provided with a preventive medicine visit, it should be attached to the office-based E/M code (99202–99215).
5. The separately billed E/M service must meet documentation requirements for the code level selected. It will sometimes be based on MDM or total time spent on the acute or chronic problem.

Other issues include the importance of linking each CPT service provided to a distinct International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic code. This clearly supports the medical necessity of furnishing the E/M 25 service separate from another procedure or E/M service. However, while a separate ICD-10-CM code may help to support medical necessity for the 2 distinct services, CPT points out that it is not always required.

Some insurance companies may require separate co-payments on both services. This requirement is subject to the family’s plan benefit design and is not controlled by you, the provider. You are contractually obligated to comply with the plan’s requirements. It should be pointed out to the family that there would be another co-payment if the patient returned for another encounter to address the problem. This would require a significant additional investment of time and would be inconvenient.

Some payers, continue to fail to recognize modifier 25 and its appropriate use.

The bottom line is to maximize your efficiency seeing patients and maximize their convenience in your medical home by providing medically necessary services at the time of another significant and separate E/M service or procedure. However, know your payer and its policy with this complicated coding area. You don’t want to get caught not receiving payment for the work you do or with a potential Medicaid payback! The Academy continues to advocate and support the use of separate payment for reporting.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.