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CPT Modifier 25 (GEN) - Revised 8-28-07
Posted August 28, 2007
The full description of modifier 25 is found in Appendix A of the Current Procedural Terminology (CPT) Manual, appropriate to the year of the service. It is a significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service. The 25 modifier should only be used on claims for evaluation and management (E&M) services. That is, it is attached to the E&M service, not to the procedure from which the E&M service is a significant, separately identifiable service. The E&M service and the procedure may be based on the same diagnosis or they may be differing diagnoses. Each service must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient's medical record to support the claim for the services.
Precaution is presented that carriers may not permit the use of CPT modifier 25 to generate payment for multiple E&M services on the same day by the same physician. For office and outpatient E&M visits provided on the same day, this contractor may not pay two E&M office visits billed by a physician, or a physician of the same specialty from the same group practice, for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting, which could not be provided during the same encounter. For example, an office visit in the morning for blood pressure and medication evaluation and five hours later, a visit for evaluation of leg pain following an accident. This could be paid as unrelated services in the office or outpatient setting and that would also include the emergency department of a hospital.
If the patient has services in the emergency department or an office visit, those E&M visits on the same date provided in sites other than nursing facilities are included or bundled into the initial nursing facility care code when these are performed on the same date as the nursing facility admission by the same physician. A 25 modifier would not be appropriate in those circumstances.
Another time when it is appropriate to use the 25 modifier is with drug administration services and E&M visits on the same day of service. An E&M service higher than a CPT code 99211 that is necessary, significant, and separately identifiable in addition to one or more of the drug administration codes, may be reported with a modifier 25. Also, in this instance, a different diagnosis is not required.
In addition to the Initial Preventive Physical Examination (IPPE) or the "Welcome to Medicare" physical, CPT codes 99201-99215 may be used depending on the clinical appropriateness of the circumstances. CPT modifier 25 shall be appended to the medically necessary E&M service identifying this service as a separately identifiable service from the IPPE code, which is code G0344. Some of the components of a medically necessary E&M service, for example, a portion of the history or physical examination, may have been part of the IPPE and should not be included when determining the most appropriate level of E&M service to be billed for the medically necessary E&M service.
The global surgical fee would include hospital observation services unless the criteria for use of CPT modifier 25 are met.
An example of an office E&M service and an office procedure which are unrelated and would justify the use of a 25 modifier, could be an upper respiratory infection and during that examination, a large amount of impacted cerumen is noted in one or both ear canals, the physician would carry out the history and examination in relation to the upper respiratory infection with appropriate plan for treatment and could proceed to remove the impacted cerumen in the patient's ear canal or ear canals. The modifier 25 would be appended to the E&M service, and the CPT code for the removal of impacted cerumen, separate procedure, one or both ears, would be separately reported.
Preventive medicine services are noncovered, represented by codes 99381-99397. Within a preventive medicine service, there may be a medically necessary service combined. For example, when scheduled for and undergoing a preventive medicine service, an E&M service may be provided in relation to the condition of hypertension for which a patient is under care. That portion of the service which is a billable E&M service could be separately identified with a 25 modifier and paid. The preventive service remaining would be the patient's responsibility to pay the provider and would not be covered by Medicare.
The 25 modifier may be appended to an E&M service provided on the day of the procedure with a global fee period and in which the services are above and beyond the preoperative work of the procedure. Modifier 25 can be applied to procedures with a post-operative period of 90, 10, and 0 days. The procedures with 10 or 0 days are considered minor surgery and the note to describe the condition of the patient requiring the minor surgical procedure would include appropriate documentation and would not justify a separately identifiable service ordinarily.
For critical care services by a surgeon during the global period for a seriously injured or burned patient, the critical care must be above and beyond and unrelated to the specific anatomic injury or surgical procedure performed.
This would only be in the pre-operative care of the patient; modifier 24 would be used for the post-operative period, not modifier 25.
Modifier 25 may be used with the code G0101 (Cervical or vaginal cancer screening, pelvic and clinical breast examination). The 25 modifier would be reported with the E&M service, which would be in addition to the G0101 service.
Prolonged services do not require a 25 modifier. Prolonged services are billed with defined companion E&M codes.
The 25 modifier is not used for the E&M service that results in the initial decision to perform surgery on the day before or the day of surgery. For that E&M service, modifier 57 would be appended. For a decision to perform a minor surgical procedure, this would typically be done prior to the service and would be considered a routine pre-op service without a separate visit or consultation billed in addition to the procedure.
Two hospital visits on the same day are combined per day. A 25 modifier is not used. The E&M CPT code should represent all services for the day, if more than one visit is made to the same patient by the same office, although it might be different physicians of the same specialty from that office, only one E&M CPT code is submitted for payment.
At times, the 59 modifier is used incorrectly for E&M services. The 59 modifier should only be used for procedures. |
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