Modifier 25 – EM and Other Services on the Same Day

By Steve Adams, CPC, CPC-H, CPC-I

CPT modifier -25 is used when, on the day a procedure or service was performed, the patient’s condition required a significant and separately identifiable evaluation and management (E/M) service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

However, with the submission of a claim with a modifier -25 attached to an E/M service you are indicating that documentation is available, in the patient’s records, for review upon request.  It is not uncommon for the carrier to review the documentation of a provider that used a modifier -25 to ensure the E/M code that was billed with the procedure/service in fact supported the significant and separately identifiable nature of the E/M service.

Whenever you are using a modifier -25 on an E/M to indicate a significant and separately identifiable E/M service I offer the following three tips:

1)       Have two separate notes when billing an E/M visit with a preventive visit on the same day – don’t make the carrier try to identify what portion of your note is for the well visit and what part is for the “sick” visit.  Remember, the 25 modifier means SIGNIFICANT AND SEPARATELY IDENTIFIABLE.

2)       If billing an E/M with a minor surgical procedure (0-10 day global period), make sure you have documented something “above and beyond” what would be considered typical “pre-operative” decision making for the surgery – remember, anything that led to the decision to do the minor surgery on the same day as the minor surgery is bundled into the payment for the minor surgery.  Only those things “above and beyond” the typical pre-operative evaluation are actually billable.

3)       While it’s not required, I still recommend using separate diagnosis codes – it makes it more clear to the payer and the provider that significant separately identifiable services have been performed.

In closing – all surgical procedures and some procedural services include a certain degree of physician involvement or supervision which is integral to that service.  For those procedures and services a separate E/M service is not normally reimbursed. 

However, a significant and separately identifiable E/M service may be eligible for additional reimbursement if the patient’s condition required services above and beyond the usual care associated with the procedure or service being provided.  To identify these circumstances correctly and survive a pre or post payment review, remember the three tips from above, and always assume this is the note that will be requested for review.

Comments are closed.