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Modifier 25

National Government Services has identified problems common with claims submitted for evaluation and management (E&M) Services where modifier 25 was appended. This article is designed to provide education regarding the correct coding and documentation requirements for these services, thereby reducing future payment errors. 

Use of modifier 25 indicates a “significant, separately identifiable E&M service by the same physician on the same day of the procedure or other therapeutic service.” Both services must be significant, separate and distinct. In general, Medicare considers E&M services provided on the day of a procedure to be part of the work of the procedure, and as such, does not make separate payment. The exception to that rule is when the E&M documentation supports that there has been a significant amount of additional work above and beyond what the physician would normally provide, and when the visit can stand alone as a medically necessary billable service.

Through the process of medical review we have found providers frequently fail to produce documentation that is sufficient or convincing enough to support billing for both services. 

When billing an E&M service along with a procedure, your documentation must clearly demonstrate that:

  • the purpose of the evaluation and management service was to evaluate a specific complaint;
  • the complaint or problem addressed can stand alone as a billable service;
  • you performed extra work that went above and beyond the typical work associated with the procedure code;
  • the key components of the appropriately selected E&M service were actually performed and address the presenting complaint;
  • the purpose of the visit was other than evaluating and/or obtaining information needed to perform the procedure/service; and
  • both the medically necessary E&M service and the procedure are appropriately and sufficiently documented by the physician in the patient’s medical record to support the claim for these services.

Following are examples that illustrate the appropriate use of modifier 25:

  • A patient is scheduled by the podiatrist to take care of a fibrous hamartoma. During the visit, the patient indicates that he has had numbness and oozing from a lesion on his heel. The podiatrist evaluates the lesion, determines that it is a diabetic ulcer and treats it appropriately.
    • In this case the heel lesion is considered a separate and significant service.
  • 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.
  • A patient comes to the office with complaints of right knee pain. The physician takes a history and does an exam. An X-ray of the knee is obtained and the physician writes an order for physical therapy. He determines that the patient would benefit from a cortisone injection to the affected knee.
    • In this case, a separate and significant E&M service was prompted by the knee pain for which the cortisone injection was given.

Following are examples that illustrate the inappropriate use of modifier 25:

  • An established patient is seen in the office for debridement of mycotic nails. In the course of examining the feet prior to the procedure, Tinea Pedis is noted. Use of previously prescribed topical cream to treat the Tinea is recommended.
    • In this case the Tinea was noted incidentally in the course of the evaluation of the mycotic nails and did not constitute a significant and separately identifiable E&M service above and beyond the usual pre and postcare associated with nail debridement.
  • 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 postwork for the laceration.

In all cases where modifier 25 is appropriately employed, the provider must ensure that documentation is present in the patient's medical record to fully substantiate both the visit and the procedure.

Documentation for the E&M service must include the key elements (history, examination, and medical decision making) that are required for the selected code.

As a result of this education, we would expect that providers will use modifier 25 only when they can clearly substantiate that the visit was medically necessary, significant and distinctly separate from the procedure or therapeutic service they provided to the same patient on the same date of service.

Health care providers have a professional obligation to communicate accurately and effectively what is being done and planned in the care of each patient. You should always strive to make your documentation clear, concise, and legible. When you are asked to furnish documentation to support services under review, legible documentation will help to ensure more accurate determinations during the review process. You may be asked to provide typed notes so that your documentation can be clearly read.

As a provider, it is important that you are knowledgeable regarding billing practices pertinent to your specialty area. You have the responsibility to investigate all available sources for appropriate codes, documentation and billing requirements.

Local coverage determinations (LCDs) are an invaluable reference and can be accessed through the National Government Services Web site. Within the LCD you will find, among other things:

  • Descriptions of each covered service
  • Which services are covered and reimbursable
  • Proper coding for the services provided
  • A description of the documentation requirements to support the claim, and
  • ICD-9 Codes that support or do not support medical necessity for a particular service

From the www.NGSMedicare.com home page you can access LCDs specific to your state/region by selecting:

  • your Business Type;
  • your Region;
  • the Medical Policy Center link under the Quick Links heading; then
  • the Active link in the Local Coverage Determinations navigation table

You can also access additional information on E&M services in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6. (902 KB)

Modifier 25
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