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Modifier 25 Fact Sheet

Definition

  • 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." The same physician concept also applies when the exact same physician performs services.

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.

Appropriate Usage

  • 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.
  • 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.

Inappropriate Usage

  • 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 for a new patient.
  • 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.

Procedure codes:

  • 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.

Modifier 25 applied correctly example

The physician appended modifier 25 to the wrong code.

Modifier 25 appended to wrong code example

Special situations

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.

Page Last Updated: Tuesday, 15-Jul-2014 09:21:18 CDT