What is Modifier 25?

• Definition: Used to report a significant, separately identifiable Evaluation and Management (E/M) service performed on the same day as another procedure by the same physician or qualified healthcare professional.

Appropriate Use:

• Applies when an E/M service is distinct from the procedure or usual pre/postoperative care.
• Can be appended to E/M codes (99202–99215) when paired with a procedure (e.g., 93015 Cardiovascular stress test).
• Does not require different diagnosis codes for E/M and the procedure.
• Documentation must clearly support the medical necessity for both services.

Examples:

• Appropriate Use: Patient has an E/M visit for chest pain and undergoes a cardiovascular stress test the same day. Use Modifier 25 with the E/M code.
  • Example coding: 99214, 25 and 93015.
• Inappropriate Use: Patient comes in solely for a scheduled stress test. Only the test should be coded (e.g., 93015).

Rules to Remember:

• Documentation: Must substantiate the E/M service as separate and significant from the procedure.
• Link Modifier 25 to the E/M CPT code.
• Modifier 25 is valid for minor surgical procedures (000 or 010-day global period) or non-global indicator (XXX) procedures.
• Do not use Modifier 25:
  • For services during a postoperative period if related to prior surgery.
  • When only an E/M service is performed without a procedure.
  • For major surgeries (90-day global period) unless unrelated to the surgery.

Additional Notes:

• Proper use informs payers to reimburse for both E/M and the procedure.
• Audits often result in payment rescission for inadequate documentation or incorrect coding.
• Modifier 25 can be used for outpatient, inpatient, ambulatory surgery centers, and emergency department visits.