What is the UHC modifier 25 policy?
Asked by: Joanny Price Jr. | Last update: November 15, 2025Score: 4.4/5 (45 votes)
What is the modifier 25 policy?
Modifier 25 should be appended to the office or other outpatient visit code to indicate that a significant, separately identifiable E/M service was provided on the same date as the preventive medicine E/M service, and the appropriate preventive medicine E/M service is additionally reported without a modifier.
What is the 25 modifier on UB?
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.
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.
2025 Inflation Reduction Act and Medicare Part D Changes
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 much does a modifier 25 reduce a 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.
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.
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.
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.
Does modifier 25 go before 95?
When billing a telemedicine service (using modifier 95) and another service that requires modifier 25 to be used in addition, the general rule is to report the “payment” modifier before any other descriptive modifier. Since both modifier 25 and 95 can impact payment, list modifier 25 first.
Can modifier 25 be used with G0378?
appropriate to use modifier 25 on any code other than an E/M code. E/M codes include CPT codes 99201-99499 or any HCPCS code that is used to identify an E/M service, including, but not limited to, G0378, G0379, G0438, G0439, or G0463.
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.
Can an office visit be billed with an injection?
It is true that an evaluation and management code, an E/M or office visit, can be reported with a minor procedure such as an injection, but only if the E/M is significant and separate and exceeds the “pre-service evaluation” that is inherent to the injection.
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 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.
What is the difference between modifier 25 and modifier 59?
Modifier -59, “Distinct Procedural Service,” is similar to modifier -25, but it's applicable to procedural, rather than E/M, services.
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.
How do you know if its 99213 or 99214?
The primary difference between CPT code 99213 and 99214 lies in the complexity and time involved. While 99213 is for a low level of medical decision-making, 99214 is used for moderate complexity, requiring a higher level of medical decision-making and more extensive history and examination.
Can you bill 99213 for telehealth visit?
During the COVID-19 public health emergency, many physiatrists are performing standard office visits via telehealth. These services should be billed using standard E/M codes. For example, a level 3 office visit provided to an established patient via telehealth should be billed using code 99213.
Can I use modifier 25 on a preventive visit?
This code can help you to get reimbursed for the extra work you do at certain visits. Many times a patient's “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more.
Can you use modifier 25 with Medicare?
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.
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.