RT Welter’s Modifier 25 Factsheet

The HHS Office of Inspector General (OIG) made a recent addition to their Work Plan which specifically cites dermatology as their primary area of focus in regard to use of modifier 25. The updated Work Plan indicates that on average, 60% of dermatologists submit claims for E/M services also include minor surgical procedures, a much higher rate than most other specialties. Keep in mind, these statistics come from data of unaudited records, but a thorough analysis of coding patterns can start to raise eyebrows when one becomes an outlier.

According to the OIG, a high rate of E/M claims with modifier 25 “may indicate abuse.” Having a solid understanding of the appropriate use of modifier 25 can help clinicians be more confident and compliant when documenting and reporting separately identifiable services. Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service.

Here are a few tips on appropriate use of modifier 25:

  • Modifier 25 indicates that on the day of a procedure, the patient’s condition required a significant,
    separately identifiable E/M service, above and beyond the usual pre and post-operative care associated
    with the procedure or service performed. All procedures have an “inherent” E/M service included. This
    definition indicates the importance of a well-written note that captures evidence that evaluation and
    management of the problem occurred, supporting medical necessity for a separately identifiable service
  • Modifier 25 should be appended to the illness service code (ie, 99202-99215) when performing
    wellness/illness/procedure on same day.
  • DO NOT report E/M when patient presents for a pre‐planned procedure.
  • If decision today is for major surgery within the next 24 hours (90 global days), use ‐57 instead.
  • Do not use a 25 Modifier when billing for services performed during a postoperative period if related to
    the previous surgery.
  • It is not necessary to have two different diagnosis codes.
  • Modifier 25 can be used for outpatient, inpatient, and ambulatory surgery centers hospital outpatient
  • Modifier 25 can be used in other locations, ie, critical care and emergency department visits.
  • Individual payers may have contradictory policies regarding modifier 25 usage since guidelines from the
    AMA and the Centers for Medicare and Medicaid Services (CMS) differ.

Examples of appropriate use of modifier 25:

  • An established patient sustained a severe laceration to the scalp. Before suturing the laceration, the physician
    performed and documented a comprehensive history and exam to determine if the patient sustained neurological
    damage. Evidence of this evaluation is documented clearly, supporting 99214-25. The physician then performed a
    3.0 cm intermediate repair (12032) to the scalp.
  • Patient presents with shoulder pain and other problems: The physician evaluates the shoulder before performing
    the arthrocentesis, also evaluates other problems (hypertension and diabetes). Based on the documentation,
    reporting an E/M and the procedure on the same day with a modifier 25 appended to the E/M would be
  • A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise.
    The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is
    determined that the patient needs a cardiovascular stress test that is performed that day by the same physician.
    99214-25 & 93015 are supported.
  • 43 yof presents for preventive visit w/complaint of right knee pain after recent accident. A comprehensive
    preventive exam is performed as well as management of knee pain. F/U in 2 weeks. Supports 99396 & 99213‐25.

Example of inappropriate use of modifier 25:

  • A patient was scheduled to have a lesion removed from her right leg. The physician examined the lesion, infiltrated
    the lesion with 1% lidocaine. The lesion was removed, and a simple closure (11401) was performed. The sole
    purpose for the visit was for the lesion removal; therefore, billing an E/M with modifier 25 would not be
  • Patient complains of a troublesome lesion. Lesion is evaluated and removed during the visit. The surgical code
    includes the evaluation service necessary before the performance of the procedure, no E/M code is warranted.

The bottom line is: The burden of proof falls upon the documentation for the services rendered. How clear is the story about what occurred during the encounter? Will your documentation support both codes? Does it support medical necessity? Typically, when these services are audited, payment is rescinded due to incorrect coding, incomplete
documentation, and/or lack of medical necessity to support both codes billed on the same day by the same
physician. Document what you do, code what you document.

Please reference the 2021 AMA CPT coding book for full definition of the codes.
CPT 2021
CPT Principles 9 th Edition
PartBNews, Vol. 35, Issue 23


-Ginger Avery, CPC, CPMA, CRC
Coding & Compliance Manager