When not to use modifier 25?
Asked by: Prof. Frankie Runolfsdottir IV | Last update: December 11, 2025Score: 4.2/5 (51 votes)
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.
What is the CMS rule for 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.
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
Which scenario qualifies for modifier 25?
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 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 I use modifier 25 on a preventive visit?
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.
How does modifier 25 affect 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 ...
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 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 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.
Can you bill an office visit and hospital visit on the same day?
The article suggests that if a physician sees a patient in the office on a given day and then admits the patient to the hospital that same day, the physician can bill both the office visit (99201–99215) and the admit (99221–99223) as long as he or she waits to visit the patient in the hospital on the following date.
What is the criteria for modifier 25?
Modifier 25 is used to signify that when a separate identifiable evaluation-and-management (E/M) service was performed, which can refer to two evaluation-and-management (E/M) services, or a procedure plus an E/M service.
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 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.
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.”
Is modifier 25 needed for immunizations?
Yes, you bill the immunizations separate from the well-child visit, with the -25 on the visit. in fact, if you read the introduction to the Preventive Medicine Services (page 36 in the AMA Professional CPT edition), it states "Vaccine/toxoid products, immunization administrations.....are reported separately".
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 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.
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.
What is the modifier for two ER visits same day?
What is the modifier for two visits on the same day? The modifier commonly used for reporting two E&M visits on the same day is modifier 25. It signifies a significant, separately identifiable E&M service provided by the same healthcare professional on the same day.
What is the difference between a 99213 and a 99214 visit?
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.
Which of the following cannot be counted for time-based E&M coding?
The only time that can be included in the calculation of total time is the time personally spent by the physician or QHP on the date of the encounter. Again, ancillary staff time cannot be counted; this includes medical assistants, patient care technicians, licensed vocational nurses, licensed practical nurses, etc.
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.