QUEST Integration - Modifier Code 25

Modifier code 25 should be used to identify significant, separately identifiable evaluation and management services (E/M) performed by the same physician on the same day as a procedural service. E/M services may be billed only with procedural services when the patient’s medical condition requires services beyond those normally provided with the procedural services, or beyond the usual pre-operative and post-operative care normally associated with the procedural services.

Modifier code 25 should not be used to report an E/M service resulting in a decision to perform surgery.

Examples:

Example 1 (Billing an E/M visit with modifier code 25 in accord with this policy)

A child falls from his bicycle and is taken to his family physician’s office. The child has a scrape wound on his knee that must be cleansed and bandaged, a 6 cm laceration on his lower leg that must be sutured and a large contusion on his head that causes the physician to evaluate him for a possible traumatic concussion.

Because of the amount and complexity of medical decision making involved with the visit, the physician may bill an E/M service using modifier code 25. If the child did not have the contusion or other symptoms of possible concussion, the physician would bill for the laceration repair only.

The physician's services would be represented on the CMS 1500 claim form as follows:

Example 2 (Billing an E/M visit with modifier code 25 in accord with this policy)

A patient is referred to a gastroenterologist for a proctosigmoidoscopy because of a positive reading on a fecal blood occult screening test. Before the procedure begins, the patient complains of being “faint” and “short of breath.” Although the physician suspects that these symptoms may be caused by the patient’s apprehension about the test, he performs an examination to rule out other causes that might contraindicate continuing with the procedure. An E/M service may be billed using modifier code 25, because such an examination generally is not considered to be part of the proctosigmoidoscopy.

The physician's services would be represented on the CMS 1500 claim form as follows:

Example 3 (Billing an E/M service with modifier code 25 would not be in accord with this policy)

A diabetic patient presents to his dermatologist with a 1.5 cm neoplastic lesion on his lower leg. The dermatologist removes the lesion, and the pathology report indicates that it is benign. The major service performed was the removal of the lesion.

Even though the patient is diabetic, a factor the physician must take into consideration when he or she removes the lesion, no separately identifiable service is performed to evaluate or treat the patient’s diabetes. Therefore an E/M visit would not be billed. However, because the patient’s diabetes is a comorbid condition affecting the physician’s medical decision making, it should be listed on the claim form as a secondary diagnosis.

The physician's services would be represented on the CMS 1500 claim form as follows:

Claims Filing Information

When billing an E/M service with modifier 25, list all applicable diagnoses in Block 21 of the CMS 1500 claim form. Be sure that each service listed in column 24D is linked with the appropriate diagnosis indicator in column 24E. However, please keep in mind that though a chronic condition may be listed on the claim (as in example 3), modifier code 25 should not be used unless the physician is providing active treatment or medical management of the condition during the same visit.

The physician's documentation should indicate clearly that a separately identifiable medical condition was treated in addition to the condition that necessitated the procedural service. These notes will help HMSA staff determine that modifier code 25 has been used appropriately.

Revision History