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Proper Use of the 25 Modifier

Centers for Medicare & Medicaid Services (“CMS”) closely evaluates the proper use of modifier 25 by physicians. In order to utilize modifier 25 correctly, please review the following helpful tips included below.

Ensure the E/M service is unrelated to and separate from the procedure. CCI policy states the 25 modifier may be used with an E/M code “to indicate that the E/M service is significant and separately identifiable from the other services reported on the same date of service.” Modifier 25 should therefore be reserved for the unexpected and unrelated.

Audit your own medical records to make sure the same day E/M documentation stands up to scrutiny. When reviewing a patient’s medical record, if you would remove the documentation for the given procedure, does the remaining documentation support the separate level of E/M service that is billed? If the documentation is not sufficient on its own to support the E/M service, the E/M service with the 25 modifier is not billable.

Note the global period of surgery and use the 25 modifier only if another service arises. Do not use the 25 modifier to submit a claim for a physician visit on the same day of the minor surgery, injection or service if the only documentation stated is that the decision to perform the procedure was made. This same day visit is always included in the same day procedure. As a general rule, if the patient is scheduled for a procedure or diagnostic testing, there is no need to have E/M services billed when no other separate problem arises.

Please don’t hesitate to contact Precision if you have any questions regarding the proper use of the 25 modifier.