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    Everything doctors need to know about modifier 25

    Q: I’m not sure when to bill an office visit (with modifier 25) and a minor procedure. Can you give me some direction to pass along?

    A: Modifier 25 is tricky and can always use some important reminders of its proper application.

    Modifier 25 Defined

    Modifier 25 is defined as a “significant, separately identifiable evaluation and management (E/M)service by the same physician on the same day of the procedure or other service.” 

    So let’s break the definition down.   

    Significant:  In order to support an E/M code, the work must be significant. This can be defined as a problem that requires considerable workup or treatment, or a problem that, if not addressed at today’s visit, would require the patient to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M service in addition to a procedure.

    Separately identifiable:  The documentation needs to support the elements of an E/M service that are over and above what a provider would perform pre-operatively for the procedure that day. While it isn’t required to document the E/M visit separately from the pre-op work, the documentation should clearly support the work that was performed to support a separate E/M visit.

    A few rules to remember when using Modifier 25:

    1. Always link the modifier to the E/M Current Procedural Terminology code. 

    2. It is not necessary to have two different diagnosis codes. 

    3. Both the E/M and the procedure need to be documented.

    4. Modifiers are needed to inform third-party payers of circumstances that may affect the way payment is made—the modifiers tell a story of what is actually being done!

     

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