Everything doctors need to know about modifier 25

Q: I’m not sure when to bill an office visit (with modifier 25) and a minor procedure. Can you give me some direction to pass along?

A: Modifier 25 is tricky and can always use some important reminders of its proper application.

Modifier 25 Defined

Modifier 25 is defined as a “significant, separately identifiable evaluation and management (E/M)service by the same physician on the same day of the procedure or other service.” 

So let’s break the definition down.   

Significant:  In order to support an E/M code, the work must be significant. This can be defined as a problem that requires considerable workup or treatment, or a problem that, if not addressed at today’s visit, would require the patient to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M service in addition to a procedure.

Separately identifiable:  The documentation needs to support the elements of an E/M service that are over and above what a provider would perform pre-operatively for the procedure that day. While it isn’t required to document the E/M visit separately from the pre-op work, the documentation should clearly support the work that was performed to support a separate E/M visit.

A few rules to remember when using Modifier 25:

1. Always link the modifier to the E/M Current Procedural Terminology code. 

2. It is not necessary to have two different diagnosis codes. 

3. Both the E/M and the procedure need to be documented.

4. Modifiers are needed to inform third-party payers of circumstances that may affect the way payment is made-the modifiers tell a story of what is actually being done!

Proper use of Modifier 25

A new patient presents with head trauma, loss of consciousness at the scene and a 4.2 cm scalp laceration. The physician determines that the laceration requires sutures, so he performs a simple repair. Due to the loss of consciousness, the physician also performs a full neurological examination with an expanded problem-focused history, expanded problem-focused examination and medical decision making of low complexity. 

In this example, the problem/abnormality is significant enough to require the additional work of the key components of a problem-oriented E/M service separate from what was needed for the laceration repair. So this visit would be coded as follows:

12002

99202 -25

The possible neurological damage from the head trauma extended beyond the laceration, which was repaired. The full neuro exam, history and medical decision making outside of the laceration issues are separate and distinct, significantly separate and well documented to support the use of modifier 25.

Improper use of Modifier 25

An established patient returns to the orthopedic physician with escalating right knee pain 6 months post a series of Hyaluronan injections. After evaluating the knee and the patient’s medical suitability for the procedure, the physician determines a second series of Hyaluronan injections is needed and performs the first of three intra-articular injections. 

It would not be appropriate to bill the E/M visit with modifier 25 because the focus of the visit is related to the knee pain, which precipitated the injection procedure. The evaluation of the knee problem and the patient’s medical suitability for the procedure is included in the injection procedure since all procedures have an “inherent” E/M service included. Therefore, the documentation only supports the procedure (20610).