Modifiers are appended to the Evaluation and Management (E&M) Current Procedural Terminology (CPT®) codes to further explain or document services. According to the Centers for Medicare & Medicaid Services (CMS), Modifier 25 is added to the E&M code when there is a “significant, separately identifiable E&M service performed by the same physician or other qualified healthcare provider on the same day as the initial procedure or other service.”
All procedures include the usual pre-operative and post-operative care normally associated with the procedure. By billing Modifier 25, the provider indicates that the patient’s condition requires additional workup and a “significant, separately identifiable E&M service” beyond the usual pre-operative and post-operative care associated with the procedure. Noting minor problems that do not require additional workup does not satisfy the requirements for billing Modifier 25.
Example 1: The patient comes in for a fourth manipulative chiropractic treatment. The provider documents a brief history and an exam and notes that the patient has benefited from the previous manipulative treatments. The patient consents to the procedure. Is Modifier 25 appropriate to bill?
No. The limited assessment of the patient is included in the chiropractic manipulation and is not considered to be beyond the normal components of the procedure. Modifier 25 may be appropriate to bill if there is an established patient but presents with a new condition, a new injury, a re-injury, or an exacerbation of a stable condition, or if a re-evaluation to determine if a change in treatment is necessary is performed. Documentation must clearly reflect these circumstances to support billing with Modifier 25.
Example 2: The patient returns to the office for additional care of burn wounds that are not healing. The physician evaluates the patient’s vascular status and counsels the patient about diabetic care and compliance with medications. The physician debrides the wounds. Is Modifier 25 appropriate to bill?
Yes. The debridement procedure would be billed with an E&M code and Modifier 25 for the significant and separately identifiable service of determining why healing is not progressing, which in this case, is due to poor circulation or noncompliance with diabetic treatment.
Example 3: An established patient has been diagnosed previously with severe headaches and comes in for additional Botox injections. The documentation notes that the previous Botox injections have been helpful. The patient gives consent for the procedure. Is Modifier 25 appropriate to bill?
No. Modifier 25 is not appended to an E&M service when a minimal procedure is performed. In this case, the assessment is inherent to the injection procedure. The service is not significant or separately identifiable so only the procedure should be billed.
Example 4: The patient presents with a head laceration that requires a simple repair. The patient makes comments during the procedure preparation that prompt the provider to examine the patient for neurological damage before repairing the laceration Is Modifier 25 appropriate to bill?
Yes. This assessment is necessary based on new information. A complete neurological exam would not normally be performed during the pre-operative assessment for a simple laceration repair.
When a provider is evaluating a patient’s condition and deciding whether or not to perform a minor procedure, the assessment is included in the procedure code. An E&M code should not be billed.
When a procedure is to be performed, Modifier 25 is only appended to the E&M codes when a provider performs separate, significantly identifiable services from the procedure that are not normally performed with the procedure. The documentation must support the use of the modifier.
Modifier 25 is not used if the physician is only performing an E&M service.
If you have any questions or need additional information, please contact Pinnacol’s provider medical billing auditors at 303.361.4940 or billingsuccess@pinnacol.com.