Rules for Modifier 25

The appropriate use of Modifier 25 can be a little tricky because the requirements are ultra-specific. On the one hand, Modifier 25 is really handy. It creates the opportunity to capture additional physician work done when separate E/M services are provided at the time of another E/M visit or procedural service. And, it’s a more efficient use of both the physician and patient’s time by saving additional trips to the doctor’s office.

However, Modifier 25 is famous for invoking frustration for a number of reasons. One being that many payers, including Medicaid, don’t recognize it. Not to mention it’s just difficult to understand specifically when a provider can use Modifier 25. For most auditors, it’s a huge pain in the neck.

While Modifier 25 can be pretty confusing, there are rules for appropriate use:

• If Modifier 25 is used, the documentation must show that the E/M service was significant and medically necessary. It must require treatment with a prescription or an E/M service that would require a return visit.
• To use Modifier 25, the E/M service must be separate and distinct from the other E/M service provided.
• The E/M service must be provided on the same day as the other procedure or E/M service, either during the same encounter or as a separate encounter (on the same day).
• The provider must attach Modifier 25 to the E/M code.
• The provider must provide adequate documentation for the separately billed E/M service.

Want even more information on Modifier 25?

Tune in for our upcoming webinar, Modifier 25: Unraveling E/M Services, to learn when it’s appropriate to use Modifier 25, crucial payer information including medicaid and insurance exceptions, and regional MAC guidelines.