Modifier 25: The Little CPT Code that Could

Patient care is always at the forefront of any good physician’s mind. But billing is a close second; after all, you can’t keep the lights on at your practice if you aren’t properly reimbursed. That’s why this article covers modifier 25, a Current Procedural Terminology (CPT) modifier many physicians in wound care and other healthcare disciplines use—but may not be sure of all best practices. Keep reading to learn more about this modifier, how it should be used, the consequences of potential misuse, and more.

10 Things Physicians Should Know About Modifier 25

1. What Is Modifier 25?

Modifier 25 is a CPT code modifier that indicates a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.

“Its use allows two E/M services or a procedure plus an E/M service that are distinctly different but required for the patient’s condition to be appropriately reported and, therefore, appropriately paid,” reads an American Medical Association (AMA) issue brief on modifier 25.

About CPT Codes Current Procedural Terminology (CPT) is widely accepted medical nomenclature in the U.S. It’s used to report singular or multiple medical services and procedures to public and private health insurers. CPT codes are essential for accurate billing and insurance reimbursement and are used to classify and report medical procedures and services, ensuring that providers are compensated appropriately. They can also help in public health and research measures.

2. Why Is Modifier 25 Important?

Modifier 25 is an important CPT code modifier because it:

• Enables accurate, additional reimbursement. When used appropriately, modifier 25 enables you to accurately bill for significant, separately identifiable E/M services provided on the same day as a procedure. This ensures fair compensation for your time and expertise involved in addressing a separate medical issue during patient encounters.
• Provides flexibility in patient care. By allowing for the billing of separate E/M services, modifier 25 encourages providers like you to address multiple medical concerns during a single visit, improving patient convenience and potentially reducing the need for additional appointments.

3. When Should Modifier 25 Used?

Let’s say you performed a procedure on a patient. During that same visit, you also addressed a separate and significant medical issue that required a level of E/M service beyond what’s typically included in the procedure itself. This type of scenario is best suited for using this modifier.

Consider this example: A patient comes in for a scheduled wound cleaning. During the visit, you also discover an unrelated concerning heart murmur. You conduct a thorough cardiac examination, order an EKG, and discuss treatment options.

In this case, you could use modifier 25 with the E/M code to indicate that you provided a significant, separate E/M service for the heart condition in addition to the wound debridement procedure for which the patient initially visited.

Medicare Exception for Modifier 25 The AMA brief mentioned above indicates that Medicare allows an exception to the same-day guideline for procedures and other services. Medicare will allow use of modifier 25 when an E/M service is reported with a global procedure, which includes visits and other physician services for a specified number of days after the service is provided.

4. When Should Modifier 25 NOT Be Used?

Modifier 25 should NOT be used when performing:

• Routine pre-operative or post-operative care. E/M services that are considered part of the usual care associated with a procedure—such as pre-operative history and physical examinations or routine post-operative checkups—generally do not qualify for modifier 25.
• E/M services that are integral to the procedure. If the E/M service is essentially a component of the procedure itself, it should not be separately billed with the modifier. For example, if the E/M service primarily focuses on obtaining informed consent for the procedure, it may not be considered separately billable.
• Minor procedures with inherent E/M. Many minor procedures have an inherent E/M component included in their coding. In these cases, a separate E/M service with modifier 25 is generally not appropriate unless the E/M service is truly significant and distinct from the procedure.
• Any service where documentation does not support its use. It’s crucial to have clear and concise documentation in the medical record to support the use of modifier 25. If the documentation does not adequately justify the need for a separate E/M service, payers may deny your claims.

5. What Are the Consequences of Misusing Modifier 25?

Modifier 25 is generally considered a high-risk modifier. Payers are aware of the potential for abuse and frequently audit claims that include it, so it should only be used when truly warranted.

Inappropriate use of modifier 25 can lead to:

• Denial of claims. Payers may deny claims if they believe modifier 25 was used incorrectly, resulting in financial losses for your practice.
• Audits and investigations. Improper use can increase the risk of extensive audits of your practice’s coding and billing practices from payers and government agencies, which can be time-consuming, costly, and disruptive to your practice’s workflow.
• Recoupment. In some cases, payers may request recoupment of payments already made for claims where modifier 25 was used improperly.
• Reputational damage. Inaccurate coding practices can damage the reputation of the practice with payers and potentially harm patient trust.
• Legal and ethical concerns. Inappropriate use of modifier 25 may raise concerns about fraud and abuse, which can have serious legal and ethical consequences.

6. What Are the Documentation Requirements for Modifier 25?

To successfully use modifier 25 and receive proper reimbursement, your medical records must clearly and concisely represent:

• A significant and separately identifiable E/M service. Document the key components of a problem-oriented E/M service, which includes a detailed history, examination, and medical decision-making (MDM) related to the separate medical issue. Demonstrate that the E/M service extends beyond the typical pre- or post-operative care associated with the procedure.
• A clear distinction from the procedure. Clearly differentiate the E/M service from the procedure itself. Explain how the two services are distinct and address separate medical concerns.
• A medical necessity. Document the medical necessity of the E/M service. Explain why it was clinically appropriate to address this separate medical issue during the same patient encounter.
• Time spent. Document the time spent with the patient for both the procedure and the separate E/M service, if applicable.

7. What Are the Distinctions between Modifier 25 vs 59?

Modifier 25 and 59 are often used in similar ways. However, modifier 25 is specifically for E/M services, while modifier 59 is more general—it can be used for a variety of services, not just E/M services.

Modifier 25 highlights the medical necessity of the E/M service beyond the usual pre- or post-operative care associated with the procedure, while modifier 59 emphasizes the distinct and independent nature of a service from other services performed on the same day.

National Correct Coding Initiative (NCCI) edits prevent the billing of certain pairs of codes together (as described in more detail in the next section). Modifier 59 can be used to override an NCCI edit when the services are truly distinct.

8. What Are the Differences Between Modifier 24 and 25?

Modifier 25 and modifier 24 are also used in similar fashion. However, modifier 24 is typically used during the postoperative period rather than the same day as the procedure.

Under modifier 24, the E/M service addresses a condition unrelated to the surgical procedure during the postoperative period. For example, say a patient has surgery related to a wound and then visits you for a follow-up visit during the postoperative period. During this visit, they also bring up an unrelated issue, such as a skin rash. This is where you’d use modifier 24.

9. How Do NCCI Edits Impact the Use of Modifier 25?

The National Correct Coding Initiative is a program developed by the Centers for Medicare & Medicaid Services (CMS) to promote correct coding methodologies and control improper coding that leads to inappropriate payments.

NCCI edits are the program’s coding policies and guidelines. They are constantly updated and help prevent Medicare from paying for services that are considered redundant or not medically necessary. Staying up to date on and adhering to NCCI edits helps minimize the risk of your claims being denied due to coding errors.

NCCI edits include:

• Procedure-to-procedure (PTP) edits. These edits identify pairs of CPT codes that should not be reported together on the same day for the same patient. This is because one code is considered to be included in the other.
• Medically unlikely edits (MUEs). These edits define the maximum number of units that can be billed for a specific CPT code on a single day.

NCCI edits are designed to prevent inappropriate payment for services that are considered bundled together. So if an E/M service is considered part of the typical care associated with a procedure, NCCI edits may prevent the use of modifier 25.

It’s essential to understand the specific NCCI edits related to the procedures you perform. This knowledge can help you determine whether modifier 25 is appropriate and how to navigate potential coding challenges.

If you believe an E/M service is truly significant and separately identifiable, you may need to submit a claim with modifier 25 and appropriate documentation to override the NCCI edit. This may require a peer-to-peer review or other appeals processes.

10. How Do Payer Policies Vary When Using Modifier 25?

Payer policies regarding modifier 25 can vary significantly in several ways.

• Acceptance of modifier 25: Some payers may have specific policies regarding the use of modifier 25 with certain procedures or in specific clinical scenarios. Some may have limited acceptance or even deny claims with modifier 25 under certain circumstances.
• Documentation requirements: Payer requirements for documentation to support the use of modifier 25 can vary. Some may have stricter requirements than others.
• Reimbursement rates: Payers may have different reimbursement rates for E/M services billed with modifier 25. Some may reduce reimbursement rates, while others may have specific payment policies for such services.
• Audit and review processes: Some payers may have more stringent audit and review processes for claims with modifier 25 to ensure appropriate use.

To ensure you are billing appropriately and maximizing your chance at full and timely reimbursement:

• Review payer-specific policies. Always consult the specific payer policies for each patient’s insurance plan to understand their specific requirements and limitations regarding modifier 25.
• Stay informed. Payer policies can change frequently. It’s important to stay informed about any updates to payer policies that may affect the use of modifier 25.  
• Seek guidance. If you have any questions or concerns about the use of modifier 25 with a specific payer, consult with a coding expert or seek guidance from the payer directly.

Stay Informed About Modifier 25

Always consult with legal and coding experts for the most up-to-date guidance on modifier 25 and its application in your specific practice setting. By understanding the risks and adhering to appropriate coding practices, you can minimize the risk of audits and denials related to this high-risk but beneficial CPT modifier and ensure accurate reimbursement for your services.