Understanding the 25 Modifier in Medical Billing

Introduction

In medical billing and coding, modifiers play a crucial role in accurately reporting the circumstances surrounding a performed service or procedure. The 25 modifier in medical billing, is known as “significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.” While the 25 modifier has not undergone revision for the CPT 2023 code set, there is often confusion regarding its appropriate use. This article aims to provide a comprehensive understanding of the 25 modifier, outlining its appropriate use, and key considerations, and providing examples of its application.

Appropriate Use of Modifier 25

The 25 modifier in medical billing is used to indicate that a patient’s condition required a significant, separately identifiable E/M service in addition to another procedure or service performed by the same physician or qualified health care professional (QHP) on the same day. The E/M service must be above and beyond the usual preoperative and postoperative care associated with the procedure or service performed on that same date. It is important to note that the E/M service is prompted by the symptom or condition for which the procedure or service was provided, and different diagnoses are not necessarily required for the reported E/M services on the same day.

Notable Considerations for Correct Reporting

To ensure the proper usage of the 25 modifier, healthcare professionals should keep the following considerations in mind:

Limited to E/M Services

The 25 modifier should only be appended to E/M services codes. Instructions emphasizing this point can be found throughout the CPT code set, including specialized subsections such as Hemodialysis, Allergy and Clinical Immunology, and Drug Infusions.

Awareness of Preoperative and Postoperative Services

When reporting an E/M service alongside another procedure, the E/M service should encompass work performed beyond the usual preoperative and postoperative services associated with the procedure performed on the same date. Healthcare professionals need to be aware of what services are included in a surgical package, as these should not be reported separately.

Applicable with Multiple E/M Services

In certain cases, multiple E/M services may be performed and reported on the same date. In these situations, the appropriate E/M code(s) should be appended with the 25 modifier. Detailed guidelines for reporting in these circumstances are provided in the E/M services’ respective subsections, such as preventive medicine services and newborn care services.

Documentation of Significant, Separately Identifiable E/M Services

A significant, separately identifiable E/M service should be substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. Adequate documentation is crucial to support the medical necessity of both the E/M service and the accompanying procedure.

Examples of Appropriate Usage

A patient visits a cardiologist with complaints of occasional chest discomfort during exercise. After conducting an office visit, the physician determines that a cardiovascular stress test is necessary and performs it on the same day. In this case, the appropriate coding would be:

• 99214, 25 (Office or other outpatient visit for the evaluation and management of an established patient)
• 93015 (Cardiovascular stress test)

The 25 modifier is added to the E/M visit to indicate that a separately identifiable E/M service was provided on the same day as the procedure.

Examples of Improper Usage of 25 Modifier

• It is equally important to understand scenarios where the 25 modifier should not be used:
• Do not use the 25 modifier when billing for services performed during a postoperative period related to the previous surgery.
• Do not append the 25 modifier if there is only an E/M service performed during the office visit without any accompanying procedure.
• Do not use the 25 modifier on the day a “Major” (90-day global) procedure is being performed.
• Do not append the 25 modifier to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant and separately identifiable.

To conclude,

Proper usage of modifiers in medical billing is essential to ensure accurate reporting and appropriate reimbursement for healthcare services. Healthcare professionals should be aware of the specific scenarios where the 25 modifier in medical billing is applicable and ensure proper documentation to support its usage. By understanding the appropriate use of the 25 modifier, healthcare providers can streamline their billing processes and mitigate potential billing errors or denials.

About PrimeCare

PrimeCare is a reputable medical billing company renowned for its expertise in accurate medical coding, including the appropriate use of modifiers in medical billing. With our in-depth knowledge of coding guidelines and regulations, our team ensures that modifiers, such as the 25 modifier, are applied correctly. Our commitment to meticulous coding practices and adherence to industry standards result in precise billing, reducing the risk of errors and denials. Trust us to handle your medical coding needs with precision and expertise. Contact us today to learn more about medical billing services.