When to use Modifier 25

By Aimee Wilcox, MA, CST, CCS-P

What is Modifier 25?

Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant and separately identifiable EM service above and beyond that which is usual for a pre- and post-operative care that is associated with the surgical procedure.

I saw my dermatologist for treatment of some dermatitis on my scalp that was itching and making me crazy. He wrote me a prescription for Prednisone and a special shampoo to help my scalp heal. He asked if there was anything else he could do for me and then I quickly remembered I had this suspicious spot on my neck that was not healing well and definitely wasn't going away. I asked him to examine it, which he did, and recommended that I immediately have it biopsied. The biopsy was performed during the same office visit as my EM service.

Modifier 25 is used to report an evaluation and management service that is significantly unrelated to the surgical procedure performed on the same day. The two services I received were significantly different from each other and the procedure was not planned for the same day but rather occurred as a spontaneous decision made at the time of the physical examination.

Modifier 25 must be appended to an EM code and not a procedure or other service code.

What would happen if no modifier was appended to the EM service?

Without modifier 25 appended to the EM service, it would be denied as incidental to the surgical procedure performed the same day. In other words, the insurance company would believe that it was a preoperative service and deny it as included in the global package attached to the surgical procedure.

When the decision for surgery is made at the time of an EM service, but is performed as major surgery (not in the office), modifier 25 is not applicable. Rather, modifier 57 would be appended to the EM service to indicate this fact.

Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding.

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