In healthcare billing, a modifier is a two-character code that provides additional information about a service or procedure performed. While modifiers do not change the original definition or code, they are a means to indicate that the service or procedure was altered by a specific circumstance, which can ultimately impact billing and reimbursement. Modifiers also enable healthcare professionals to effectively respond to payment-policy requirements established by other entities.
For a full list of modifiers and their definitions, you can refer to Appendix A of the Current Procedural Terminology (CPT).
One of the most common modifiers in healthcare billing is Modifier 25, which is used when a healthcare provider performs distinct services on the same day. The following criteria apply when using Modifier 25:
- Modifier 25 only applies to Evaluation and Management (E/M) services, such as office visits, consultations, or hospital rounds.
- The service must be performed by the same physician or other qualified healthcare professional on the same day as the procedure or other service.
- The E/M service must be significant and separately identifiable from the procedure and/or service that was provided.
- The E/M service may be prompted by the symptoms or condition for which the procedure and/or service was provided; as such, different diagnoses are not required for the E/M services reported on the same date.
To reiterate, Modifier 25 is appended to only the E/M code when a significant and separately identifiable E/M service is performed on the same date as a minor procedure with 0-10 global days.
Examples of when you CAN use Modifier 25:
- A patient has a scheduled procedure, and the physician also needs to provide an E/M for a new issue. Modifier 25 can be reported to show that the E/M service is independent.
- A Preventive Medicine E/M service or annual well visit is provided with a problem-oriented office or other outpatient E/M service. In these cases, Modifier 25 should be appended to the "traditional" office visit code.
Examples of when you CAN'T use Modifier 25:
Note that Modifier 25 should not be used if the documentation only supports the procedure, or if the visit is for a scheduled injection/procedure.
- The patient's condition does not change – For example, if a patient is scheduled for an injection but their condition doesn't change, and they plan to return for a future date for the injection, then Modifier 25 should not be used.
- The service is related to a previous surgery – For example, if a patient has a post-operative service related to a previous surgery, then Modifier 25 should not be used.
- The procedure is routine – For example, if a patient has a small skin lesion removed in a routine procedure, and no other conditions are treated, then Modifier 25 should not be used. Since minor surgical procedures and XXX-global procedures include pre-service, intra-service, and post-service work inherent in the procedure, the physician cannot report an E/M service for this work in most circumstances when the minor surgical procedure or XXX-global is the primary procedure.
As with all matters of provider service billing, understanding the necessity and justification for services performed is mandatory. Particularly with Modifier 25, clear and detailed physician documentation is key to demonstrating the thought process and supporting the medical decision making (MDM) involved during the treatment rendered. If you have any questions or would like support with your healthcare billing practices, please contact us to learn more.
Christie Blubaugh is a Coding Specialist at Medic Management Group. MMG is a national provider of advisory and consulting competencies, transaction support services, and back office administrative support to independent and system owned physician practice groups.