Modifier 25

As defined by the American Medical Association (AMA), modifier 25 indicates a significant, separately identifiable evaluation and management (E/M) service performed by the same physician or other qualified health care professional on the same day as a procedure or other service.

Correct use of Modifier 25

• All procedures contain an inherent E/M service component.
• CPT codes in the E/M section of the AMA CPT manual (see below).
• E/M and another service or procedure are performed on the same day, and
• Documentation supports separate reporting of an E/M service, and
• E&M service may be prompted by the symptom or condition for which the procedure and/or service was provided.
• When a visit occurs on the same day as a surgery with ‘0’ global days, and within the global period of another surgery, and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted.

Incorrect use of Modifier 25

• Not appropriate with laboratory or pathology codes (append modifier 91).
• Do not add the 25 modifier to procedure/surgical/vaccine administration codes.
• Should not be attached to multiple line items billed on same claim.
• Does not replace modifiers such as RT, LT, 50, E1-E4, FA, F1-F9, TA, and T1-T9.
• Not appropriate for return/follow-up visits of injection therapy (Ortho).

Modifier 25 Denials/Reconsideration/Med Records Review

• CO97: Bundled/inclusive service same day.
• M80: Not covered when performed during the same session/date as a previously processed service for the patient.
• Most claims submitted with modifier 25 are reviewed during the claims adjudication process to ensure that the modifier is being used appropriately (common on corrected claim with 25 modifier added to E&M code).
• For reconsideration of a denied claim line with modifier 25, send the request and the supporting documentation as you would any other request for reconsideration.

Modifier 25 examples/scenarios