surgical CPT code with modifier 25 - example of usage

Modifier 25

25 Modifier Significantly Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the 25 modifier to the appropriate level of E/M service.

Medicare requires that CPT modifier 25 should only be used on claims for evaluation and management services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service. Medicare pays for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre and postoperative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier 25 is added to the E/M code on the claim.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

Modifier 25 Examples

Example 1: The patient sees the physician for knee pain. After examining the patient, meeting the criteria for the E/M and making the determination at the time of the visit that the patient needs a joint injection, the physician may use the 25 modifier on the office visit and be paid for the injection also.

Example 2: The physician tells the same patient in Example 1 to come back to his office in two weeks for another injection for the same complaint. He may not bill an office visit with the 25 modifier along with the joint injection. He may only bill the joint injection because this was planned prior to the visit and the criteria for an E/M service would not have been met.

Example 3: An office visit and suturing a scalp wound could be properly billed together with the use of a 25 modifier if a full neurological examination was made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status. In the circumstance when the decision to perform a minor procedure is typically done immediately before the service (e.g., whether or not sutures are needed to close a wound, whether or not to remove a mole or wart, etc.), it is considered a routine preoperative service and a visit or consultation should not be reported in addition to the procedure.