EM Coding Alert

Question: We worry about using modifier 25 incorrectly. Can you explain key considerations and provide tips on proper application?

Missouri Subscriber

Answer: Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) applies when a provider performs an evaluation and management (E/M) service on the same day as a minor procedure or service. Before appending modifier 25 to the E/M code, make sure the E/M service is significant, the documentation substantiates this, and the physician’s work is medically necessary.

Here’s a summary of things to consider before appending modifier 25 to an E/M code to avoid misuse:

E/M Service

• The same physician must provide the separate E/M service and the procedure/service for the same patient on the same day. All providers who bill under the same National Provider Identifier (such as physicians who share an NPI in a group practice) are, from a coding perspective, the “same” provider.
• Modifier 25 is appropriate when the decision to perform a diagnostic procedure is made during a significant and separately identifiable E/M. The E/M work should be significantly more than what would be performed when determining whether to do the diagnostic procedure.
• The E/M service must be significant and separately identifiable, and the extended E/M work must be medically necessary. All procedures have an inherent E/M service included, so only append modifier 25 when the E/M work goes above and beyond that usually associated with the minor procedure.
• You do not need a separate diagnosis to justify a same-day E/M service with modifier 25. Your provider must perform and document an appropriate history and exam, as well as a decision-making process that includes attention to more than the patient’s targeted chief complaint that is the reason for the minor procedure/service.

Global Period

• Modifier 25 is appropriate when an E/M service is provided on the same day as a minor procedure; defined as one with a 0-day or 10-day global period.
• Do not use modifier 25 when billing for services performed during a postoperative period if related to the previous surgery. Related, follow-up examinations by the same provider during the global period of a previous procedure are included in that procedure’s global surgical package.
• Append modifier 57 (Decision for surgery) — rather than modifier 25 — if the E/M service prompts the decision to render a major procedure (90-day global period) within 24 hours of the E/M service.

Check with your payer for coverage specifics and guidance on proper reporting.