Coding and Billing

What You Need to Know About Modifier 25 to Maximize Your Reimbursement

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

May 4, 2022

Modifier 25 enables you to bill for two separate procedures conducted during the same exam. To ensure you are getting fully reimbursed, however, you must understand the correct way to use this modifier, including the codes it can and cannot be used with. Here are the details on the right way to use this modifier.

There still is confusion around the use of Modifier 25. As a result of that confusion, doctors are leaving money on the table. This article will help put that money back into doctors’ pockets when the doctors are coding correctly and third parties are auditing appropriately.

The American Medical Association (AMA) Current Procedural Terminology (CPT) code book defines Modifier 25 as: “a significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.”

The effect of using modifier 25 is to stop the bundling of payment of the E/M visit into payment of the procedure causing the doctor’s total payment to be decreased.

When to use Modifier 25
• This modifier should only be used on claims for E/M services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service.

• Append modifier 25 to the E/M code on the claim, not to the procedure code.

• Different diagnoses are not required when you use modifier 25.

• This modifier is not used to report an E/M service that results in a decision to perform surgery.

• The documentation should be clear that both the E/M and the procedure were medically necessary.

Examples of When NOT to Use Modifier 25
• Do not append Modifier 25 if there is only an E/M service performed during the office visit (no procedure done).

• Do not automatically report an E/M code every time you perform a minor procedure in an office or facility.

• Do not use Modifier 25 when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable.

• Do not use Modifier 25 on any E/M on the day a “Major” (90-day global) procedure is being performed.

• Do not use Modifier 25 when billing for services performed during a postoperative period if related to the previous surgery.

The 3 Most Common Reasons For Denial When Using Modifier 25
• Incorrect coding

• Incomplete documentation (must document “a significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service”)

• Lack of medical necessity to support both codes billed on the same day by the same physician

Now that you know when to use and when not to use Modifier 25, pull 10 records where you used the modifier to make sure you used it correctly.

NCCI FAQs | CMS
Appropriate Use of Modifier 25 – American College of Cardiology (acc.org)
Modifier 25 – Guidelines,usage and example of using with other modifiers – Medical billing cpt modifiers and list of Medicare modifiers.
Modifier 25 fact sheet (novitas-solutions.com)

To Top
  
Subscribe Today Free...
And join more than 25,000 optometric colleagues who have made Review of Optometric Business their daily business advisor.
YOUR EMAIL
FIRST NAME
LAST NAME
  
Subscribe Today Free...
And join more than 25,000 optometric colleagues who have made Review of Optometric Business their daily business advisor.
YOUR EMAIL
FIRST NAME
LAST NAME
Subscribe Today for Free...
And join more than 35,000 optometric colleagues who have made Review of Optometric Business their daily business advisor.
Subscribe Today for Free...
And join more than 35,000 optometric colleagues who have made Review of Optometric Business their daily business advisor.