Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

April 13, 2021

Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

 

Why is modifier 25 important?

Modifier 25 used to indicate a significant, separately identifiable E/M service was performed by the same physician or other qualified health care professional on the day of procedure.

  • E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided
  • Different diagnosis is not required for reporting of E/M service
  • Documentation must support E/M level selected

 

Many payers believe modifier 25 is the most used and abused modifier, as a result they often request documentation to support the use of this modifier. This is why it is essential that documentation must be clear that the E/M service goes above and beyond the usual preoperative and postoperative cares associated with the procedure performed.

 

An example of appropriate use would be:

 

A patient sees a dermatologist for a lesion on his leg. During the exam, the patient mentions a rash on his arm. The symptoms have been worsening so that the patient has been unable to sleep at night due to the itching. The lesion on the leg is removed and the provider writes a prescription for the rash.

 

In this case the rash is considered to be a separate and significant service.

 

An example of inappropriate use:

 

A patient is seen in the office for simple repair of a laceration of the right finger. It is determined that it has been longer than ten years since his last Td vaccine. After the repair, the wound is dressed, wound care instructions are given and a Td booster is administered.

The work done is considered part of the typical care associated with this type of injury. An E&M component is included in the pre and post-work for the laceration.

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