Modifier 25 is used to describe a

"significant and separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service."

Note: Unlike under Medicare, Priority Health does not treat providers within the same specialty as a single physician. Claims are processed and clinical edits applied by each rendering physician.

• Modifier 25 should be appended only to E/M service codes within the range of 92002-92014, 99201-99499, and with HCPCS codes G0101 and G0175.
• Minor procedures already include E/M elements; only use modifier 25 when services are performed over and above what is typical for the procedure.
• The physician will need to indicate that the patient's condition required a service above and beyond what is expected for other services provided on the same day.
• Documentation within the medical record must support the level of E/M service reported.
• Notes are also required when you resubmit a code with modifier 25.

Incorrect uses of modifier 25

No other services on the same day: E/M services reported with modifier 25 and no other claim lines or services performed by the same provider on the same date of service will deny.

Example: Provider A performs a level IV E/M service, 99214, and provider B performs a vaccine administration, 90471. Provider A has not performed a significant, separately identifiable service, so would not append modifier 25 to 99214.

Decision to perform major surgery: Do not use modifier 25 to report an E/M service that resulted in a decision to perform a major surgery (use modifier 57 instead). A major surgery is defined as having a 90-day global period.

Exception: Critical care services with the decision to perform minor/major surgery, Priority Health follows CMS guidance using modifier 25 to report critical care services (CPT code 99291 and 99292) that result in a decision to perform a minor/major surgery.

When notes are required

Priority Health requires medical record notes when you re-submit a professional claim reported with CPT codes 99211-99215 and modifier 25 in addition to a minor procedure (minor procedures are defined as having a 0 or 10-day global period) and/or additional E/M services, on the same day of service following a claim denial.

If the E/M was billed originally without modifier 25 and the claim hits a clinical edit, a provider will need to submit a corrected claim with modifier 25 along with medical records.

Documentation must support a significant, separately identifiable service from a minor procedure or additional evaluation and management service performed on the same date for additional reimbursement. For example, if you submit a claim with CPT code 11200 and 99213-25, you would need to provide medical record notes supporting a significant, separately identifiable E/M service. If you don't provide notes, the claim will be denied.

This requirement follows the CMS criteria below.

When medical records are not required

Here are examples of when E/M services billed with modifier 25 will NOT require medical records on corrected claim submission:

E/M services billed only with vaccine administration codes

• 90460
• 90461
• 90470-90474

E/M services billed only with tobacco cessation codes

• 99406-99407

E/M services billed only with code

• 96372, subcutaneous injection

E/M services billed only with ultrasound and laboratory codes

• Ultrasounds and laboratory claims no longer require medical records following original clinical denials

CMS criteria for the use of modifier 25

Per CMS National Correct Coding Initiative, Chapter 11:

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E/M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E/M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.

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