Are you using modifier 25 correctly?
Asked by: Dee Erdman Sr. | Last update: November 25, 2025Score: 4.5/5 (73 votes)
How do you use modifier 25 correctly?
Appending the CPT modifier 25 to an E/M service code on a claim indicates the code is a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service, the AMA issue brief (PDF) explains.
What are the CMS guidelines for using modifier 25?
Use modifier 25 (same-day significant, separately identifiable E/M service) on the claim when you report critical care services unrelated to the service or procedure that you perform on the same day. You must also document the medical record with the relevant criteria for the respective E/M service you're reporting.
Why is modifier 25 being denied?
Key considerations for reporting modifier -25
Because the removal of the foreign body included the pre- and post-operative services, in this case, the use of modifier -25 would not be appropriate. If the doctor of optometry were to use the modifier, a claim audit would likely result in it being denied.
Which of the following is true about attaching modifier 25?
Modifier 25 can only be attached to an E/M code. Both an E/M code and a procedure code must be submitted by the same physician on the same day as the procedure.
MEDICAL CODING MODIFIER 25 - Compliantly bill an E&M and separate service on the same date
What is modifier 25 not used for?
Modifier 25 should not be used when: ❌ The sole purpose of the encounter is for the procedure (e.g., lesion removal), and there is no documented medical necessity for a separate E/M service.
Is true or false modifier 26 indicates the professional component of a procedure?
What you need to know. Modifier 26 is defined as the professional component (PC). The PC is outlined as a physician's service, which may include technician supervision, interpretation of results and a written report. Use modifier 26 when a physician interprets but does not perform the test.
Does modifier 25 impact payment?
Automatic reduction in payment for the second code to account for what they perceive to be “overlap” between the two codes (e.g., a Preventive Medicine Service E/M code reported with an Office or Other Outpatient Service E/M code appended with modifier 25 allows payment of the Preventive Medicine Service code at 100 ...
Does 99213 need a modifier 25?
If the E/M is not bundled into the stress test, then the Cardiologist's coder can use modifier 25 to indicate that these two services were separate and significant: 99213-25, 93015.
What modifier is not accepted by Medicare?
GZ - Service is not covered by Medicare
The GZ modifier identifies that 1) an item or service is expected to be denied as not reasonable and necessary, and 2) no advance notice of non-coverage was supplied to the member.
Does an EKG require a 25 modifier?
You should not use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on an E/M code (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient) when ...
Can you bill both modifier 25 and 57 together?
Both Major and Minor Surgeries on the Same Day When a decision for surgery includes both major and minor surgeries and is made the day of surgery, the E&M billed for the decision must have both modifier –57 and modifier –25 appended.
What are the new guidelines for modifier 25?
Do not use modifier 25 by a physician other than the physician performing the procedure or physician of the same specialty in the same group practice. Do not use modifier 25 when documentation does not support a significant, separately identifiable E/M service.
How do you know if a modifier is used correctly?
- Always place modifiers as close as possible to the words they modify. ...
- A modifier at the beginning of the sentence must modify the subject of the sentence. ...
- Your modifier must modify a word or phrase that is included in your sentence.
Does modifier 25 or 95 go first?
Since both modifier 25 and 95 can impact payment, list modifier 25 first.
What is modifier 25 example?
Modifier 25 is appended to indicate that a significant, separately identifiable E/M service was performed by the same physician or other QHP on the same date. A 25-year-old female (new patient) with a soft tissue breast lesion is referred to the surgeon by her primary care physician.
What are the rules for 99213?
- Medical Necessity: Healthcare providers need to explain why the visit was needed. ...
- Time-based Documentation: Providers need to spend 20-29 minutes with the patient, which is surely required to help them with decision-making.
Can you add modifier 25 to 99214?
Yes, you can add modifier 25 to CPT code 99214 if a significant, separately identifiable E/M service is performed on the same day as another procedure.
Can you bill modifier 25 and 24 together?
You can use modifiers 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) and 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the ...
Do you need modifier 25 with 93000?
You should append modifier -25 to the evaluation and management (E/M) code, but you should not need additional modifiers for 69210, “removal impacted cerumen (separate procedure), one or both ears,” or for 93000, “electrocardiogram, routine ECG with at least 12 leads; with interpretation and report,” because these ...
What is the UHC modifier 25 policy?
For example, the description for modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service) specifies that it is to be reported with an Evaluation and Management (E/M) service.
When not to use modifier 26?
Do not append modifier 26 if there is a dedicated code to describe only the professional/physician component of a given service (e.g., 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).
Which of the following are true about attaching modifier 25?
Which of the following are true about attaching modifier 25? Both an E/M code and a procedure code must be submitted by the same physician on the same day as the procedure. The E/M service must be significant and clearly separate. Modifier 25 can only be attached to an E/M code.
How are modifiers shown in CPT?
The most common CPT modifiers are nominated by letters or numbers. For example, the modifier -22 indicates increased services, while -52 means reduced fees. Other modifiers include -59 for distinct procedural service, -95 for telehealth, and -96 -97 for habilitative and rehabilitative services, respectively.