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January 11, 2018

Modifier 25

Modifier 25 is used to identify a separate and significant identifiable Evaluation and Management (E/M) service when performed by the same physician or other qualified health care professional on the same day of a procedure or other service. This means that on a day a service or procedure is performed, the patient’s condition may need a separate, significant identifiable E/M service above and beyond the service which was already provided or beyond the usual pre/postoperative care that was associated with the procedure performed.  Modifier 25 is one of the most commonly misused modifiers.

A couple of examples to further explain this concept:

  1. A patient comes in for actinic keratosis lesions (CPT 17004-010 global days) procedure code. Upon exam the physician notes a mole which appears irregular in shape. He decides to perform a biopsy (CPT 11100-000 global days) on the mole while the patient is in the office. The provider may NOT bill an E/M code with the Modifier 25 since both CPT procedure codes being billed have global days with the E/M component included.
  2. A patient comes in for actinic keratosis lesions (CPT 17004-010 global days) procedure code. Upon exam the physician notes a lesion which appears irregular in shape, suspicious for melanoma with a history of melanoma and needs excision (CPT 11400 or 11600-010 global days). Due to the provider’s schedule, excision is not possible to add on another procedure this date. Therefore, the E/M would be payable for this date of service since a significant and separately identifiable problem was found upon examination but no global procedure was performed for the lesion this date. The patient comes back days later for the excision. An E/M would not be payable with modifier 25 when the patient returns for the CPT 11400 or 11600.

    NOTE: Providers should not purposely schedule a patient out after the global period in order to bill. The provider must document a valid reason for doing so as to not appear to be circumventing the CMS payment system and possible further actions.

  3. The podiatrist is seeing a patient for nail debridement. Upon exam of the right foot, the podiatrist notes a bony mass on the side of the foot. Patient states the mass has been quite painful for the past three days. The podiatrist queries the patient about the mass and examines the area closely. He then gets an x-ray as part of the work-up. This work-up is considered separate and significant; therefore, you would be able to append the 25 modifier to the visit.

Remember when coding for procedures, the E/M visit is “built into” that CPT code. If the patient has a separate and significant problem that does not relate to the procedure billed, then it would be appropriate to bill an E/M visit with the 25 Modifier.

For more information on modifiers, please use our Part B Modifier Finder tool located on our CGS website (www.cgsmedicare.com) under the Tools section.

References:

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