Policy No: 103
Originally Created: 11/01/2008
Section: Modifiers
Last Reviewed: 06/01/2023
Last Revised: 06/01/2021
Approved: 06/08/2023
Effective: 07/01/2023
Policy applies to: Group and Individual & Medicare Advantage
This policy applies only to physicians and other qualified health care professionals, hospitals, and other facilities.
Current Procedural Terminology (CPT®) Modifier 25
Current Procedural Terminology (CPT®) Modifier 25 - a two-position numeric code appended to an Evaluation and Management (E&M) code to indicate a "significant, separately identifiable E&M service was provided by the same physician on the same day of a procedure or other service."
Major Procedure
Surgical procedures with a 1-day preoperative period and 90 day postoperative period.
Minor Procedure
Surgical procedures with no preoperative period and a 0 or 10 day postoperative period.
Outpatient Code Editor (OCE)
Procedure to procedure (PTP) edits are applied to outpatient hospitals.
Centers for Medicare & Medicaid Services (CMS) Hospital Outpatient Prospective Payment System (OPPS)
Payment system for procedures performed in a hospital outpatient setting.
Status Indicator S
Significant procedure, multiple reduction does not apply. These procedures or services are paid under CMS OPPS.
Status Indicator T
Significant procedure, multiple reduction applies. These procedures or services are paid under CMS OPPS.
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.
Outpatient hospital procedures and services with status indicator of "S" or "T" include some pre-procedure work, such as obtaining the patient's blood pressure, temperature, asking the patient how he or she feels, and written consent to perform the procedure. 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 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).
Modifier 25 should be appended to outpatient E&M codes as well as emergency department (ED) codes (code 99281-99285) when provided on the same date as a procedure or service that has a status indicator of "S" or "T".
Examples of Proper Use of Modifier 25
An established patient is seen for a 2.0cm 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 code, CPT 99202-99215, should be reported in addition to the preventive medicine E&M. Modifier 25 should be attached to the problem-oriented E&M code.
American Medical Association. Appendix A: Modifiers. Current Procedural Terminology (CPT). Chicago: AMA Press
Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services
Centers for Medicare & Medicaid Services (CMS). Further Information on the Use of Modifier -25 in Reporting Hospital Outpatient Services. Transmittal A-00-40, July 20, 2000
Centers for Medicare & Medicaid Services (CMS). Use of Modifier 25 and Modifier 27 in the Hospital Outpatient Prospective Payment System (OPPS). Transmittal A-01-80, June 29, 2001
Centers for Medicare & Medicaid Services (CMS), Appendix B (OPPS Only): Medical Visit Processing, Integrated OCE (IOCE) CMS Specifications
Centers for Medicare & Medicaid Services (CMS), Outpatient Prospective Payment System (OPPS)
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