What is a 25 modifier used for in Medical Billing

Sometimes Medicare patients visit the same physician for a different medical service either on the same or the next day. In such a case the physician is required to keep track of his productivity and update the latest services offered to the patients. This is where Modifier-25 comes in.

Definition of Modifier-25

In the Current Procedural Terminology (CPT) book of American Medical Association (AMA), Modifier-25 is defined as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service”. As per the Centers for Medicare and Medicaid Services (CMS) guidelines, Modifier-25 should be used by physicians and qualified non-physician practitioners (NPP) for evaluation and management (E/M) services only and no other purposes. To prevent the abuse of Modifier-25, CMS limits its use to situations “when the E/M service is above and beyond the usual pre- and post-operative work of a procedure with a global fee period performed on the same day as the E/M service”.

CMS’ Conditions on the use of Modifier-25

The following conditions are outlined by CMS in the document https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5025.pdf:

• “Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier -25 is added to the E/M code on the claim.”
• “Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient’s medical record to support the need for Modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim.”
• “Your carrier will not retract payment for claims already paid or retroactively pay claims processed prior to the implementation of CR5025. But, they will adjust claims brought to their attention.”
• “Carriers will not pay for an E/M service reported with a procedure having a global fee period unless CPT modifier -25 is appended to the E/M service to designate it as a significant and separately identifiable E/M service from the procedure. Such payment will be denied with the following messages:
  • Claim Adjustment Reason Code: 97 – Payment is included in the allowance for another service/procedure.
  • Remittance Advice Remark Code: M144 – Pre-/post-operative care payment is included in the allowance for the surgery/procedure.”

Why Prevent Modifier-25 Abuse?

Modifier-25 is used to evaluate the physician/non-physicians services in some specific situations as mentioned by CMS. Since it is related to the evaluation of a physician’s productivity by documenting the services the chances of abusing it are quite high. Therefore, it is the responsibility of physicians and the medical biller to document the exact requirement of the Evaluation and Management services separately from the previously performed procedures. Incorrect claims made by the physician can result in denials and underpayments. This will further affect the physician’s RVU (Relative Value Units) while getting compensated for his/her services. The correct use of Modifier-25 as demanded by CMS prevents hospitals from filling incorrect claims. This document is imperative to make correct payments, on-time reimbursement, and compensate doctors.