How to Use Modifier 25 correctly
Modifier 25 – this modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician. In general, the patient’s condition will drive the indication for the separate E/M service that was provided in addition to the initial procedure As such, different diagnoses are not required for reporting of the E/M services on the same date. Two important exceptions where -25 is NOT to be used include a decision to perform surgery (modifier -57) and a separate non E/M service (modifier -59).
Example: A patient visits the MFM provider for an ultrasound appointment and during this visit an anomaly is discovered within the fetus. The MFM provider has a discussion with the patient regarding the findings, discusses plans of action and further recommendations. The ultrasound report and E/M visit documentation should be distinct with separate headings, though not necessarily on two different documents.
Coding: The physician codes an E/M visit (New Patient 99201 – 99215), (Established Patient Visit 99212-99213) or (Consult Code IF requested 99241-99245) and also reports the ultrasound performed. The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure/ultrasound.The modifier stops the bundling of the E/M visit into the procedure/ultrasound. When reviewing the physician’s documentation the payer should be able to determine that both the E/M and the procedure were medically necessary. As always, the documentation for each service must support the claim sent to the carrier.
When Not to Use the Modifier 251.
- Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery.
- Do not append modifier 25 if there is only an E/M service performed during the office visit (no procedure done).
- Do not use a modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed.
- Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have “inherent” E/M service included.