Lori Carlin

Author: Lori Carlin

(303) 801-0111

Modifier 25 Scenarios

Is your documentation up to par to support Modifier 25? First, you should read The Center for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) chapter manual guidelines. Check out chapter 1 and chapter 11.

The CPT Manual defines modifier 25 as a “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.” Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).  Yes, you read that correctly – you DO NOT have to have a separate diagnosis code!

Modifier 25 may be appended to E&M services reported with minor surgical procedures (with global periods of 000 or 010 days) or procedures not covered by Global Surgery Rules (with a global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall NOT report an E&M service for this work.

  • That means the decision to perform a minor surgical procedure does NOT support modifier 25.
  • This rule applies to both New and Established patients.
  • The E&M service and minor surgical procedure do NOT require different diagnoses.
  • The NCCI program contains many, but not all, possible edits based on these principles.


Clinical Examples

Case #1: 34 y/o new patient presents to the Dermatologist with a complaint of an irritating skin tag. The provider examines the area and decides to perform cryotherapy on skin tag. The decision to perform this minor surgical procedure is included in the global period of the minor procedure.

  • This does NOT support modifier 25 with an E/M visit. Only the procedure should be coded.

Case #2: 55 y/o new patient is seen for bilateral knee pain. Patient says right knee is worse than left knee. The provider orders a bilateral knee x-ray. X-ray confirms DJD in both knees. The provider decides to perform a knee joint injection in the right knee since the patient feels the left knee isn’t that painful.

  • This DOES support a separate E/M with modifier 25 for the left knee since the provider orders an x-ray and doesn’t decide to perform a minor procedure on this knee. The joint injection procedure will be coded, and the right knee pain diagnosis will be linked to the procedure. Left knee pain diagnosis should be linked to the separately identifiable E/M on the same day.

Case #3: 25 y/o established patient comes in for a skin check and has moles on the back and arms the patient would like the provider to examine. The provider performs a full body skin exam. The provider decides to perform a skin biopsy on an abnormal looking mole on the back.

  • This DOES support a separate E/M with modifier 25 for the moles on the arms and back that the provider examined but didn’t perform any procedure. The provider would also code for the skin biopsy for the abnormal looking mole on the back.

Case #4: 40 y/o with right sided breast cancer returns for a follow up visit. Patient is doing well with no complaints. The provider reviews blood count and the patient proceeds with chemotherapy today.

  • This does NOT support modifier 25 on an E/M service with same day chemotherapy. The decision to proceed with chemotherapy is included in the infusion administration pre-service work.

Case #5: 36 y/o established patient was seen last week as a new patient and diagnosis with non-small cell lung cancer. Patient returns today without any new complaints. The provider conducts chemotherapy teaching and then the patient proceeds with chemotherapy infusion.

  • This does NOT warrant a separate E/M service on the same day as the chemotherapy administration. Chemotherapy teaching is bundled into the administration of the drug. If the provider had performed the chemotherapy teaching at the new patient visit this could have been factored into the medical decision making for the time spent on that day.

Remember, if you are reporting an E/M with modifier 25 on the same day as a minor procedure, the E/M should include work above and beyond the usual preoperative and postoperative services associated with the minor procedure performed on the same date of service. The AMA has developed a checklist of the typical pre- and post-operative services associated with a minor procedure that can NOT be reported as a separate E/M service. Those items include:

  • Review of patient’s relevant past medical history,
  • Assessment of the problem area to be treated by surgical or other service,
  • Formulation and explanation of the clinical diagnosis,
  • Review and explanation of the procedure to the patient, family, or caregiver,
  • Discussion of alternative treatments or diagnostic options,
  • Obtaining informed consent,
  • Providing postoperative care instructions, and
  • Discussion of any further treatment and follow up after the procedure.

For more information on coding compliance review services, please contact Pinnacle Enterprise Risk Consulting Services Director Lori Carlin at LCarlin@AskPHC.com.