What is Modifier 25 in Medical Billing?

Are you having trouble figuring out how modifiers actually work in medical billing? We understand that these two-digit codes add an extra layer of complexity to the already intricate billing workflow. 

Thus, our billing specialists decided to dedicate each blog to discussing a single modifier. This guide will touch upon everything you need to know about the appropriate use of modifier 25. We will discuss some examples, list its usage criteria, when you should append it, and when not.

So, if this is something of interest to you, continue reading!

Modifier 25 – Description

Modifier 25 indicates that a significant, separately identifiable evaluation and management (E/M) service was rendered by the same physician or other qualified healthcare practitioner on the same day of a procedure or other service. 

According to the American Academy of Professional Coders (AAPC) guidelines, it is mostly appended when the E/M service is rendered on the same day as another minor procedure with a 0- or 10-day global period. 

Modifier 25 – Usage Examples

Let’s take a look at a couple of real-world clinical scenarios that necessitate the use of 25, so that you get paid fairly for every rendered E/M service:

New Patient with New Problem and Minor Procedure

Picture a new 25-year-old female patient who visits the dermatology clinic. She complains about an unusual, pigmented lesion. 

Thus, the dermatologist takes her detailed history and performs an examination. Besides, he reviews the patient’s medical history, discusses sun exposure risks, and documents a differential diagnosis (melanoma vs. dysplastic, etc.).

That’s not all, the dermatologist also discusses the benefits and risks associated with a biopsy. In total, the healthcare provider spends a total of 30 minutes on the encounter.

During the same visit, the dermatologist performs a definitive tissue diagnosis, such as a shave biopsy of the lesion.

Here, the dermatologist should bill the E/M visit (CPT 99203) with modifier 25, and the shave biopsy (CPT 11102) without a modifier.

Established Patient Presenting with Multiple Problems

Consider a 38-year-old male established patient who visits his primary care physician for two distinct issues. 

First, he complains about experiencing acute symptoms of bronchitis. The provider notes down his comprehensive history and performs a physical examination, orders X-rays, and manages prescriptions.

Second, he reports a wart on his hand that has become painful. Thus, the healthcare practitioner decides to treat this existing, stable problem by performing cryosurgery of the wart during the same encounter.

You should report the E/M encounter of an established patient with moderate decision making (CPT code 99214) with modifier 25, and cryosurgery (CPT 17110) without a modifier.

When to Use Modifier 25?

Below are the key criteria that mandate the use of 25:

For New or Unrelated Problem

Append modifier 25 when the problem the physician manages is either new or separate from the reason for the procedure.

New Problem Example

A patient visits the clinic for a scheduled wart removal. However, while there, he complains about experiencing severe migraine (a new problem). Thus, the physician takes down the patient’s history, performs a physical examination, and creates/manages a treatment plan.

Here, modifier 25 is applicable to the E/M code.

Separate Problem Example

A patient comes to his primary care physician with two distinct issues. That is: (1) an infected finger requiring an incision and drainage (I&D) procedure, (2) an unrelated, acute cough requiring a chest X-ray order and medication management.

Since the cough evaluation and management were separate from the I&D service, modifier 25 is applicable to the E/M code.

For Significant, Separately Identifiable Cognitive Work

There may be scenarios where the E/M service is related to the procedure you performed on the same day for the same patient, yet modifier 25 will apply. 

If this confuses you, then it is understandable. However, continue reading for clarity.

When a situation like this occurs, you must determine whether the medical decision-making required was significant. Simply put, ask yourself, did it require more effort and work than the standard pre-procedure assessment? If yes, append the modifier.

Here’s a brief example for better understanding:

A patient is scheduled for a joint injection. However, the patient reports a sudden new loss of sensation in the limb during the pre-injection check. As a result, it became necessary for the healthcare provider to conduct an extensive neurological exam and update the treatment plan. 

Even though the problem was related, you will bill the E/M code with modifier 25. It will highlight to the payer that the service was significant and must be reimbursed separately.

When Not to Use Modifier 25?

The following are a few circumstances where you should never append 25:

When You Perform Routine Pre-Procedure Work

Did the E/M service only involve the work you would typically perform during the procedure’s global period? If yes, avoid appending modifier 25. These may include:

• Confirming that the patient is aware of the planned procedure and consents to it.
• Checking standard pre-procedure vitals of the patient.
• Review of the surgical site.
• Pre- and post-operative orders, including antibiotics or pain medication prescription.

When Evaluation is the Procedure

What happens when the primary purpose of the encounter is the procedure itself, and no separate, significant decision-making process took place? 

For instance, a patient comes to the clinic for a scheduled skin tag removal that was diagnosed during a previous encounter. The physician conducts a quick examination to locate the tag and removes it. 

Here, there is no need to bill the E/M code at all (with/without modifier) since the entire service was focused. That is, only report the removal code.

When Procedure Has a 90-Day Global Period

Remember that modifier 25 is only applicable when the rendered procedure has either a 0-day or 10-day global period. Thus, never append it if the performed procedure has a 90-day global period. 

Note: Modifier 57 is designated to E/M visits in which the physician decides to perform an urgent/emergent major procedure (90-day global period) on the same day or the next day.

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