Modifier 25 Fact Sheet
- Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure
*Same physician - Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."
All E/M services provided on the same day as a procedure are part of the procedure and Medicare only makes separate payment if an exception applies.
- Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
- Use Modifier 25 with the appropriate level of E/M service.
- The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File. This global period could be 000, 010, or 090 days.
- An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)
- Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.
- A physician other than the physician* performing the procedure.
- Documentation shows the amount of work performed is consistent with that normally performed with the procedure.
The following statements are false
- I can always use this modifier when I did not plan the procedure.
- I can always use this modifier when the diagnoses are different.
- I can never use this modifier when the diagnoses are the same.
- G0181-G0182 Care Plan Oversight Supervision
- 92002-92014 E/M Ophthalmology
- 99201-99499 E/M all locations
Example: The physician sees the patient for a condition requiring a significant and separately identifiable E/M service prior to removing a wart.
The physician appended modifier 25 to the wrong code.
Occasionally two physicians in the same group with the same specialty (but different subspecialties) see the patient on the same day. Medicare does not recognize subspecialties on front-end claims processing. The physician may use Modifier 25 if the documentation meets the definition above. Please submit the documentation when requesting a redetermination.
Situations occur when it is necessary to report multiple surgery modifiers on the same claim line.
The following is an example of appropriate reporting of both modifiers 24 (Unrelated E/M by the same physician during a postoperative period), and 25 (Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service), on the same E/M code.
A physician performs a major surgery and within the global period sees the patient for an unrelated E/M visit. During this unrelated E/M visit, the physician determines the necessity of a minor surgery or other procedure. This minor surgery/other procedure is significant and separately identifiable from the E/M and unrelated to the original major surgery. Both the 24 and 25 modifiers are appropriate to add to the E/M code. The 24 modifier is appropriate because the E/M service is unrelated and during the postoperative period of the major surgery. The 25 modifier is necessary to identify that the minor surgery/procedure performed on the same day is separately identifiable from the E/M service. In addition, the minor surgery procedure code may need a 79 modifier to indicate the procedure is not related to the major surgery.