CPT modifiers 25 question - where and when to use

If you perform a preventive care service and an immunization simultaneously, would you apply a modifier? Example: Providing an Annual Wellness Visit (AWV) and a preventive vaccination.

2A: The AWV is not an E/M service; therefore, E/M modifiers do not apply. However, you should ensure documentation is present in the medical record to support the separate immunization.



 If a new patient presents to a practice and ends up having a joint injection during that same visit, is the E/M billable? Would I use the 25 modifier?

3A: If the patient is not coming specifically for a joint injection, then 'No,' the modifier is not needed since the patient is being seen as a new patient. The modifier 25 is not needed with an initial E/M service code.

However, if the patient is established and presented for an E/M service only, and the joint injection was performed as a result of the E/M, then 'Yes,' you can bill the E/M and apply modifier 25 as long as documentation can be provided showing the medical necessity for the services




If we provide a preventive immunization (e.g., pneumococcal vaccination), should we use modifier 25?

4A: If an established patient is not coming in specifically for the preventive immunization, then 'Yes' you could apply modifier 25 to the E/M service as long as documentation can be provided showing the medical necessity for the services.



 If an initial consultation and/or follow-up office visit requires a chest X-ray, pulmonary function test (PFT) or 6-minute walk (stress test) for the purposes of evaluation, would the E/M service require modifier 25?

5A. Again, if the rationale for why the patient is there is the X-ray, PFT or stress test, then a separate E/M wouldn't be payable. However, if the patient is there for an initial consultation and the X-ray or PFT is then ordered and performed, then modifier 25 may be billed as long as documentation can be provided showing the medical necessity for the services.




 Is there a penalty when modifier 25 is inappropriately applied to a new patient visit code?

6A: Currently, there is no editing to prevent the modifier 25 from being billed with initial visits as previous guidelines did require the modifier. However, since the modifier is not required, future editing enhancements could cause the claim to be returned as unprocessable for an invalid modifier.


 If the patient presents with joint pain and has a joint injection on the same day, can we bill for both the office visit and the injection or would the documentation requirements have to be met?

7A: If the patient is new and is not coming specifically for a joint injection, then 'No,' the modifier is not needed. Since the patient is being seen as a new patient, the modifier 25 is not needed with an initial E/M service code.

However, if the patient is established and presented for the E/M service only and the joint injection was performed as a result of the E/M, then 'Yes,' you can bill the E/M and apply modifier 25 as long as documentation can be provided showing the medical necessity for the services.


When an inpatient is in a critical care unit and the physician inserts a Swan-Ganz during the visit, do we append a modifier 25 to the Current Procedural Terminology® (CPT®) code 99291?

9A. Regarding critical care services, if the services are separately identifiable from why the patient is in the hospital, then 'Yes,' the code can be billed with modifier 25 as long as documentation can be provided showing the medical necessity for the services.

Services such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter e.g., Swan-Ganz (CPT code 93503) are not bundled into critical care codes. Therefore, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier 25.

However, if the critical care is being provided due to the rationale for why they are in the hospital, then everything would be rolled up under the hospital billing.


How significant must the change in treatment plan be? Common scenario: Patient with known arthritis being managed conservatively presents complaining of increasing pain and the physician does a steroid injection to knee.

10A. If the patient has been on a specific plan regiment for a while (ex.: 3- to 6-months) and the plan changes significantly (arthritis gets extremely exacerbated or detrimentally worse), you can bill the modifier 25 as long as documentation can be provided showing the medical necessity for the services.


 A patient comes in for a post-operative visit within the global days for sinus surgery and has complaints of sinus pressure and is sneezing. Would this be considered related or unrelated? Does this allow for an E/M visit with a modifier 24?

11A. If the physician determines the pressure and sneezing is unrelated to the surgery and provides the rationale in the records, they can bill for an E/M with a modifier 24 as long as documentation can be provided showing the medical necessity for the services. Documentation will likely be requested.


If we provide an outpatient surgery on a patient (ex: 90-day global period) and admit the patient after surgery, can we bill for the admission, subsequent hospital days, and the discharge?

12A. Depends on whether the admission is related to the surgery or not. Here are some examples of services not included in the global period:

• Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care.

• Visits or hospitalization unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.

• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery

Use of modifier 24 will require documentation to be reviewed. The separate services may be billed as long as documentation can be provided showing the distinction and medical necessity for the services



The patient is billed for CPT 90960 for dialysis. During that same month, the patient goes into the hospital. Would modifier 25 go on the initial consultation and follow-up days?

13A: Documentation will be the key. Unless the services are provided on the same day, modifier 25 would not be used. Also, when an end-stage renal disease (ESRD) patient is hospitalized, the hospitalization may or may not be due to a renal-related condition. In either case, the patient must continue to be dialyzed. The separate services may be billed as long as documentation can be provided showing the distinction and medical necessity for the services.

CMS IOM Pub. 100-04, chapter 8 external pdf file provides policy and payment instructions for physicians' services furnished to dialysis inpatients. It also provides instructions for billing physicians' renal-related medical services furnished on dialysis days and for dialysis and E/M services performed on the same day.

Keep in mind, regarding the E/M visits in the hospital on the same day of dialysis, when inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure. Typically, all evaluation and management services provided on the same day as inpatient dialysis are denied without review with the exception of CPT Codes 99221-99223, 99251-99255, and 99238. These codes may be billed with modifier 25 and reviewed for possible allowance if the E/M service is unrelated to the treatment of ESRD and was not, and could not, have been provided during the dialysis treatment.


All these information are educational purpose only.  For more information http://medicare.fcso.com/


Modifier 25

The American Medical Association’s CPT Coding Manual describes the use of modifier 25 as “the physician may need to indicate that on the day of a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable 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.”

Appropriate Modifier 25 Use

** This modifier may be appended to Evaluation and Management codes (99201-99499) or to general ophthalmologic codes (92002-92014).

** This modifier should be used when the Evaluation and Management service is distinct and separately identifiable from the service or procedure being performed.

** This modifier should only be added to Evaluation and Management services in conjunction with the service or procedure (CMS’ 0 and 10 day Global Surgery periods) on the same day.


Effective for dates of service on or after July 1, 2015, when an E&M code with modifier 25 and a procedure code having a 0-, 10- or 90-day post-operative period are billed by the same provider for the same date of service, Tufts Health Plan will compensate the E&M service at 50% of the otherwise allowed amount. This policy will apply to professional and outpatient claims.



** This modifier may be appended to Evaluation and Management codes 99201–99215 and 99241–99245 or to general ophthalmologic codes (92002-92014).


USING THE –25 MODIFIER 

Modifier –25 must be appended to an E/M code when reported with another procedure on the same date of service. The E/M visit and the procedure must be documented separately.

Modifier –25 must be reported in the following circumstances to be paid:

• Same patient, same day encounter, and • Same or separate visit, and

• Same provider, and

• Patient condition required a ―significant separately identifiable E/M service above and beyond the usual pre and post care‖ related with the procedure or service.

• Scheduling back-to-back appointments doesn‘t meet the criteria for using the –25 modifier.

Example 1: A worker goes to an osteopathic physician‘s office to be treated for back pain. The physician:

• Reviews the history,
• Conducts a review of body systems and
• Performs a clinical examination The physician then advises the worker that osteopathic manipulation is a therapeutic option for treatment for the condition. The physician performs the manipulation during the office visit. This is a significant separately identifiable procedure performed at the time of the E/M service.

For this office visit, the physician may bill the appropriate:

• procedure   code for the manipulation and
• E/M code with the –25 modifier

Example 2: A worker goes to a physician‘s office for a scheduled follow up visit for a work related injury. During the examination, the physician determines that the worker‘s condition requires a course of treatment that includes a trigger point injection at this time. The trigger point injection was not scheduled previously as part of the E/M visit.

The physician gives the injection during the visit. This is a significant separately identifiable procedure performed at the time of the E/M service. For the same time and date of service, the physician may bill the appropriate:

• procedure  code for the injection and
• E/M code with the –25 modifier


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