Medical Society of Virginia

Coding Q&A: What is Modifier-25?

13 July 2009

Q: When is it appropriate to use Modifier-25?

A: Modifier-25 should be used for significant, separately identifiable evaluation and management (E/M) services by the same physician on the same day of the procedure or other service. The physician may have to show that on the day a procedure was performed, the patient’s condition required a separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

Q: How is the E/M service prompted?

A: 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 needed for reporting of the E/M services on the same day. This circumstance may be reported by adding Modifier-25 to the appropriate level of E/M service.

Q: When is it inappropriate to use Modifier-25?

A: Modifier-25 is not used to report an E/M service that resulted in a decision to perform surgery. In this case you would need to use Modifier-57. It is also not appropriate for use when the only service provided is the procedure.

Q: What needs to be proven to insurance carriers for usage of Modifier-25?

A: The phrase “the patient’s condition required” is very important for insurance carriers, as it shows them that it was medically necessary for the patient to have the service on the same day that another procedure or service was performed. The phrase “significant, separately identifiable E/M service above and beyond” other services rendered indicates that the additional service was clearly different from the other procedure that was performed.

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