Modifier 25
Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service:
The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be
reported by adding the modifier ‘-25’ to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery.
Usage
Use on E&M services only – The service must be unrelated to other services on the same day
OR
The service must be above and beyond the other service provided
OR
The service must be beyond the usual preoperative and postoperative care associated with a minor surgical or diagnostic procedure that was performed (including decision for surgery) on the same day- Per the AMA a separate diagnosis is not required to report modifier -25
Payors vary on the acceptance of this modifier. If you have questions with a payor you can request their policy in writing
Example
An established patient presents in the office for a rash, at the conclusion of the exam the patient requests a flu shot.
The E&M service is not related to the vaccine
Coding example: 99213-25, 90732, 90471
