Modifier 25 is defined as a 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.

Often questions are posed regarding whether to bill an E/M visit on the same day as a procedure or other services with modifier 25.

The following is based on the question:

Why is the patient being seen?

Other signs or symptoms

• Are there signs, symptoms, or conditions the physician or the other qualified health care professional (QHP) must address before deciding to perform a procedure or service?
  • If yes, based on the documentation, an E/M service might be medically necessary with modifier 25
  • Example:
    • An established patient was scheduled for a follow up E/M after a change in his blood pressure medications. The physician met the documentation requirements for a 99213.
    • The patient then complained he was washing dishes, dropped a glass and now his thigh muscle felt like a piece of glass went through his skin.
    • Based on the signs and symptoms documented, the physician performed 20520 (removal of foreign body in muscle or tendon sheath; simple) which has 10 global days.
    • The proper billing would be 99213 25 and 20520.

Significant or beyond normal component work

• Were the physician's or other QHP's E/M of the problem significant and beyond the normal preoperative and postoperative work?
  • If yes, an E/M may be billed with modifier 25
  • If no, it is not appropriate to bill with modifier 25
  • Example:
    • An established patient sustained a severe laceration to the scalp. Before suturing the laceration, the physician performed and documented a comprehensive history and exam to determine if the patient sustained neurological damage.
    • The physician then performed a 3.0 cm intermediate repair (12032) to the scalp.
    • Based on the signs, symptoms, and conditions documented, the physician went beyond the normal preoperative work. The proper billing would be procedure code 99215 25 and 12032.

Procedure scheduled before encounter

• Was the procedure or service scheduled before the patient encounter?
  • If yes, it is not medically necessary to bill for an E/M with modifier 25
  • Example:
    • A patient was scheduled to have a lesion removed from her right leg.
    • The physician examined the lesion, infiltrated the lesion with 1% lidocaine. The lesion was removed, and a simple closure (11401) was performed.
    • The sole purpose for the visit was for the lesion removal; therefore, billing an E/M with modifier 25 would not be appropriate.

More than one diagnosis being addressed

• Is there one or more diagnosis present being addressed or affecting the treatment and outcome?
  • If yes, bill the procedure code and the E/M with modifier 25. Medical necessity must substantiate use of the modifier.
  • Example:
    • An established patient visited her internist for a follow up of hypertension and diabetes. The patient also complained of shoulder pain.
    • The physician performed a problem focused history and exam, evaluated the patients' hypertension, and determined the blood pressure was higher than usual and adjusted the medication regimen. The patient's blood glucose was normal.
    • The physician also evaluated the shoulder and determined the patient would benefit from an arthrocentesis.
    • The physician evaluated the shoulder before performing the arthrocentesis, but also evaluated other problems (hypertension and diabetes). Based on the documentation, billing an E/M and the procedure on the same day with a modifier 25 appended to the E/M, would be appropriate.

E/M on the same day as a wellness visit

• Is payment allowed for an annual wellness visit (AWV) or an initial preventive physical exam (IPPE) on the same day as an E/M?
  • Yes, payment is allowed for a medically necessary E/M services at the same visit as the AWV or the IPPE when the E/M service is clinically appropriate and medically necessary to treat the patient’s illness or injury, or to improve the functioning of a malformed body member.
    • Components of a medically necessary E/M service (for example -- a portion of the history or physical exam) may have been part of the AWV or the IPPE and should not be included when determining the appropriate level of E/M service.
    • If all requirements are met, modifier 25 can be appended to the E/M code.
  • Example:
    • An established patient was scheduled for their AWV today. Yesterday they fell and hurt their knee.
    • The physician performed and documented a medically necessary E/M service at the same visit as the AWV. All duplicative elements were backed out of the E/M and the physician billed a 99212 with modifier 25 in addition to the AWV.

Reference

• Medicare wellness visits