What is the guidance on modifier 25?
Asked by: Abigail Kuhn | Last update: February 19, 2025Score: 4.4/5 (19 votes)
What are the rules for modifier 25?
The Centers of Medicare and Medicaid Services (CMS) requires that Modifier 25 should only be used on claims for E/M services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service.
What is a scenario in which modifier 25 would be appropriate?
Modifier 25 is a way to identify a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service,” according to the CPT 2024 code set.
Which of the following is true about attaching modifier 25?
Modifier 25 can only be attached to an E/M code. The E/M service must be significant and clearly separate. Both an E/M code and a procedure code must be submitted by the same physician on the same day as the procedure.
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.
MEDICAL CODING MODIFIER 25 - Compliantly bill an E&M and separate service on the same date
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.
How do you know if a CPT code needs a modifier?
- The service or procedure has both professional and technical components.
- More than one provider performed the service or procedure.
- More than one location was involved.
- A service or procedure was increased or reduced in comparison to what the code typically requires.
Can you bill an office visit and a procedure on the same day?
Sometimes yes, sometimes no. The decision to perform a minor procedure is included in the payment for the procedure, unless a significant and separate E/M is needed, performed and documented.
When to use modifier 25 vs 59?
Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”
Do you use modifier 25 with immunizations?
When an evaluation and management service (other than a preventive medicine service) is provided on the same date as a prophylactic immunization, modifier -25 may be appended to the code for the evaluation and management service to indicate that this service was significant and separately identifiable from the ...
Is modifier 25 needed for EKG?
Yes, you need to add a -25 modifier to your E&M service when billing in conjunction with an EKG or injection admin service done on same DOS. You're sure to get a bundling denial without it.
How to write a CPT code with modifiers?
CPT modifiers are added to the end of a CPT code with a hyphen. In the case of more than one modifier, you code the “functional” modifier first, and the “informational” modifier second.
In what scenario would you use modifier 25?
Modifier 25 is used to indicate that a patient's condition required a significant, separately identifiable evaluation and management (E/M) service above and beyond that associated with another procedure or service being reported by the same physician or other qualified health care professional (QHP) on the same date.
What are modifier rules?
Modifier Basics
A modifier is a word, phrase, or clause that modifies—that is, gives information about—another word in the same sentence. For example, in the following sentence, the word "burger" is modified by the word "vegetarian": Example: I'm going to the Saturn Café for a vegetarian burger.
Can you bill an office visit with a cast application?
A charge for procedure codes 29000-29590 is allowed only when the casting or strapping is a replacement procedure used during the period of follow-up care. The charge for an office visit is allowed only if significant identifiable further services are provided at the time of the cast application or strapping.
What is the CMS guideline for modifier 25?
Payer interpretation of modifier 25
The Centers for Medicare & Medicaid Services (CMS) requires that modifier 25 be used only on claims for E/M services and only when the E/M service is provided by the same physician on the same day as another procedure or service.
Can you bill an office visit with a preventive visit?
Physicians are not prohibited from coding and billing for both preventive and problem-focused E/M services when they are performed during the same appointment.
What is the modifier for office visit day before surgery?
Modifier 57 should be appended to any E/M service on the day of or the day before said procedure when the E/M service results in the decision to go to surgery. This informs the payer that the physician determined the surgery was medically necessary. Modifier 57 should only be appended to E/M codes.
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.
What is the proper sequencing of modifiers?
The proper sequencing order for modifiers is as follows: 1) pricing, 2) payment, and 3) location. Location modifier is always reported last in any coding scenario. Modifiers 26 and TC are examples of pricing modifiers while modifiers 51 and 59 are examples of payment. RT and LT are examples of location modifiers.
How can the incorrect use of modifiers affect reimbursement of claims?
If modifiers are missing or not used correctly, claims can be denied or rejected by insurance payers. Healthcare practices tend to suffer from aged accounts, write-offs, and revenue leakage if they do not have a firm grip on the use of modifiers.
What is modifier 25 not used for?
Do not use modifier 25 when billing for services performed during a post-operative period if related to the previous surgery. Related follow-up examinations by the same provider during the global period of a previous procedure are included in that procedure's global surgical package.
How does modifier 25 affect payment?
“Its use allows two E/M services or a procedure plus an E/M service that are distinctly different but required for the patient's condition to be appropriately reported and, therefore, appropriately paid,” the issue brief says. The use of modifiers provides supplementary information for payer policy requirements.
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.