Policy Statement
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 separate E&M service may be considered for reimbursement, if the patient’s condition required services above and beyond the usual care associated with the procedure or service provided. To identify these circumstances, modifier 25 is attached to the E&M code.
The submission of modifier 25 appended to an E&M code indicates that documentation is available in the patient’s records that will support the significant and separately identifiable nature of the E&M service.
Modifier 25 should not be appended to an E&M code used in conjunction with a Major Surgical Procedure (code having a global period of 90 days) unless there is also an unrelated minor surgical procedure performed.
Modifier 25 should be appended to E&M codes used in conjunction with a Minor Procedure (code having no preoperative period and a 0 or 10 day global period).
Our health plan does not separately reimburse E&M code(s) that are appended with modifier 25, when performed on the same day as a surgical procedure (0 or 10 day global period) if a previous face-to-face E&M code, with the same diagnosis, was billed within the prior 2 months (60 days).
Note: Member claims history with the same or related diagnosis, may be reviewed for coding validation. Providers may dispute and/or appeal claim determinations through the standard appeal process.
Modifier 25 should be appended to outpatient E&M codes as well as emergency department (ED) (codes 99281-99285) when provided on the same date as a procedure or service when the E/M is distinct and identifiable from the procedure.
Examples of Proper Use of Modifier 25
An established patient is seen for a 2.0 cm finger laceration. The patient also asks the physician to evaluate swelling of his right knee that is causing pain.
Correct Codes – CPT 12001 and CPT 99213-25
A patient was seen in the ED with complaint of shortness of breath. A 12-lead ECG was performed.
Facility Correct Codes – CPT 93005 and CPT 99281-99285 (ED services) with modifier 25
Example of Improper Use of Modifier 25
An established patient is seen for left knee pain. After evaluating the knee, the physician performs arthrocentesis.
Correct Code – CPT 20610
It would not be appropriate to bill an E&M code because the focus of the visit was the knee pain which precipitated the arthrocentesis.
Multiple E&M Services
Only one E&M service code per patient, per physician, per day is eligible for reimbursement with the following exceptions:
- The visits were for unrelated problems that could not be provided during the same encounter (i.e., scheduled office visit in the morning for ear pain and 4 hours later an unscheduled visit for a broken wrist). Modifier 25 should be attached to one of the problem-oriented E&M codes.
- If an abnormality is encountered or a preexisting problem is addressed in the process of performing a preventive medicine E&M service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E&M service, then the appropriate Office/Outpatient CPT codes (99202-99205 and 99211-99215) should be reported in addition to the preventive medicine E&M. Modifier 25 should be attached to the problem-oriented E&M code.
References
Cross References
- Adm 105 - Bundling Edits
- Adm 101 - Global Days
- Adm 133 - Preventive Medicine Evaluation and Management Visits
