Did you know reporting an E/M code and a procedure code when your evaluation is limited to only assessing the specific problem (i.e. an abscess), is essentially double-billing for the pre-service evaluation? 

Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) is an important modifier. It creates the opportunity to appropriately capture the scope of work completed, allows for a more efficient use of a provider’s time and may even save the patient another visit. However, it must be used correctly.

Here are a few things to remember to help ensure you use Modifier 25 the right way:

  • Determine the intent of the visit before appending modifier 25 to an E/M.
  • Remember, your E/M must significantly exceed the pre-service evaluation already paid as part of the procedure for it to qualify as “significant and separately identifiable service”. Otherwise, only the procedure should be billed.
  • A different diagnosis code is not required. Usually, the diagnosis code for the E/M code and the procedure are the same.
  • What must be documented is the history, exam, and decision-making process that includes attention to more than the patient’s targeted chief complaint, which is the reason for the minor procedure.

The following are examples of inappropriate usage of Modifier 25:

  • Patient presents for repeat injection of steroids for arthritis
  • Patient presents for previously planned procedure or service
  • Simple laceration repair for patient with no other complaints
  • Consultation for decision for major surgery
  • Unrelated E/M service during a previous procedure’s global period

For more information, including examples of appropriate Modifier 25 use, check out any of the following references: