Modifier 25: Everything You Need To Know in 2024

May 27, 2024

Modifier 25: Everything You Need To Know in 2024

A common area of confusion among medical practices is the appropriate use of Modifier 25. 

Modifier 25 is a specific code used in medical billing to indicate that a significant, separately identifiable evaluation and management (E/M) service was provided by the same physician or other qualified healthcare professional on the same day as another procedure or service. 

This modifier is attached to the E/M service code to distinguish it from other procedures performed on the same day.

We’ll look at exactly what Modifier 25 is, providing you with everything you need to know to use it correctly and get paid for it!

What Is Modifier 25?

Modifier 25 is a key component in medical billing, used to indicate that a significant, separately identifiable evaluation and management (E/M) service was performed by a physician (or other qualified health professional) on the same day as another procedure or service. 

Basically, it allows you to bill for an E/M service in addition to other procedures performed during the same patient visit.

Modifier 25 Description: Indicates that on the same day as a procedure, a separate and distinct evaluation and management (E/M) service was performed by the same healthcare provider, ensuring proper reimbursement for both services.

Requirements for Modifier 25

To use Modifier 25 correctly, you have to meet certain requirements:

  • Significant and Separate E/M Service: The E/M service must be distinct from other services provided on the same day.
  • Same Physician: The E/M service and the procedure must be performed by the same physician or qualified healthcare professional.
  • Same Day: Both the E/M service and the procedure must occur on the same calendar day.
  • Documentation: Detailed documentation is key. The medical records should clearly indicate that the E/M service was separate and significant.

When To Use Modifier 25

Knowing when to use Modifier 25 can significantly impact your practice’s revenue cycle.

Here are some scenarios where you can use it:

  • Initial Consultation: When a patient comes in for a consultation and, during the same visit, a minor procedure is performed.
  • Follow-Up Visits: If a patient comes in for a follow-up visit and a new, significant issue is identified that requires additional evaluation.
  • Preventive Visits: During a routine check-up, if a condition requiring separate evaluation is discovered.
  • Same Day Procedures: When a patient is scheduled for a procedure but also requires an unrelated E/M service on the same day.

When Not To Use Modifier 25

Misuse of Modifier 25 can lead to claim denials and potential audits.

Avoid using Modifier 25 in the following situations:

  • Routine Procedures: When the E/M service is not significant or separate from the procedure.
  • Preoperative Evaluations: For routine preoperative evaluations that are part of the procedure itself.
  • Lack of Documentation: If the medical records do not clearly support the separate and significant E/M service.
  • Same Service Repeated: When the E/M service is not distinct from the procedure performed.

Examples of Modifier 25

Let’s check out some examples of when you can use this:

Plastic Surgery Example

  • Example 1: A patient comes in for a follow-up visit after a rhinoplasty. During the visit, the physician identifies a significant issue with the patient’s nasal breathing that requires a separate evaluation. Modifier 25 should be appended to the E/M code.
  • Example 2: A patient scheduled for a Botox injection also presents with a new concern about a skin lesion. The physician performs a separate E/M service to evaluate the lesion.

Dermatology Example

  • Example 1: A patient visits for a routine skin check and mentions a new, suspicious mole. The dermatologist performs a separate, significant evaluation of the mole.
  • Example 2: During a scheduled acne treatment session, the patient discusses a new rash. The dermatologist conducts a separate evaluation of the rash, warranting the use of Modifier 25.

Get Medical Billing Support

At The Auctus Group, we understand the complexities of medical billing and coding, especially when it comes to modifiers like Modifier 25.

Our team of experts is dedicated to providing you with the knowledge and support you need to optimize your practice’s revenue cycle.

We prioritize making every interaction meaningful and informative, with our ultimate goal to help you grow your plastic surgery or dermatology clinic through efficient and effective billing practices.

Conclusion

Modifier 25 is an essential tool in the medical billing toolkit, allowing for appropriate reimbursement of significant, separately identifiable E/M services provided on the same day as other procedures.

By understanding when and how to use Modifier 25, you can enhance your practice’s financial efficiency and avoid common pitfalls – because who wants to deal with audits and rejected claims?

At The Auctus Group, we are committed to supporting your practice with expert billing and coding services, ensuring you can focus on providing exceptional patient care.

Contact us to level up your practice!

FAQs

What is the 25 modifier used for? 

The 25 modifier is used to indicate that a significant, separately identifiable evaluation and management (E/M) service was performed by the same physician or other qualified healthcare professional on the same day as another procedure or service.

What is the CMS rule for modifier 25? 

The Centers for Medicare & Medicaid Services (CMS) require that the 25 modifier be used to denote a significant, separately identifiable E/M service provided on the same day as another procedure. Documentation must support the necessity and distinct nature of the E/M service.

Can Modifier 25 billing be outsourced?

Medical billing outsourcing is often the answer for practices that want to grow, avoid penalties, and reduce overhead costs when it comes to staffing, billing, and rejected claims.

What is the modifier 24 and 25? 

Modifier 24 is used to indicate that an E/M service was performed during a postoperative period for reasons unrelated to the original procedure. Modifier 25 is used for a significant, separately identifiable E/M service performed on the same day as another service or procedure.

Can you add modifier 25 to 99214? 

Yes, you can add modifier 25 to CPT code 99214 if a significant, separately identifiable E/M service is performed on the same day as another procedure.

Is modifier 25 needed for immunizations? 

No, modifier 25 is not typically needed for immunizations. Immunizations usually have their specific codes and are not generally considered part of a separately identifiable E/M service.

Is modifier 25 needed for EKG? 

It depends. Modifier 25 should be used if a significant and separately identifiable E/M service is provided on the same day as the EKG. Documentation should show the necessity of the E/M service separate from the EKG.

How do you know if a CPT code needs a modifier? 

A CPT code needs a modifier when additional information is required to explain a service or procedure. Situations include when services are performed in unusual circumstances, when multiple procedures are performed during the same visit, or when separate and distinct services are provided.

Can you bill 99211 with modifier 25? 

Modifier 25 is not commonly used with 99211, as this code represents a minimal E/M service. It is rare for 99211 to justify a separately identifiable E/M service on the same day as another procedure.

Modifier 22 vs 25 

Modifier 22 is used to indicate that a procedure required significantly more work than usual. This might be due to complications or unexpected conditions that increase the complexity of the service. Modifier 25 is used to signify that a significant, separately identifiable evaluation and management (E/M) service was performed on the same day as another procedure or service. While Modifier 22 reflects increased procedural effort, Modifier 25 highlights a distinct E/M service provided in addition to a procedure.

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