Seven quick tips for using modifier 25

Many codes bundle with evaluation and management (E/M) services using modifier 25, but payers often indicate that codes that include modifier 25 are potentially abusive. (Read about Cigna's recent modifier-25 policy change in this FPM blog post and AAFP News story.)

To protect yourself from payer scrunity, here are some tips for using modifier 25 properly:

1. Never append modifier 25 to a code that is not found in the E/M section of CPT.
2. Only report modifier 25 with documentation of the E/M service sufficient to demonstrate that it was significant and not part of another service provided on the same date, as well as independently supporting the level of service reported.
3. Report an E/M service with modifier 25 when a significant and distinct E/M service is indicated even when both services are related to the same diagnosis (e.g., E/M of asthma and in-office spirometry).
   
4. Document time-based services to clearly support the total time of the E/M service (e.g., “I spent 30 minutes providing and documenting this E/M service separate from the time spent in interpretation and report of the electrocardiogram”).
5. When the purpose of the patient visit is to receive a pre-planned service, only report an E/M service when clinically indicated. Don’t report a brief E/M service that was not clinically indicated or required an insignificant amount of time or work (e.g., verifying the patient felt well and was afebrile prior to an injection).
6. Learn how each minor procedure is valued to include some pre-evaluation time, and don’t report a separate E/M code for work included in this time. For example, incision and drainage of an abscess includes eight minutes of pre-evaluation time, per the Centers for Medicare & Medicaid Services Physician Work Time file.
   
7. Perform chart reviews periodically to assess your use of modifier 25.

For more information, see:

• "Reporting CPT Modifier 25" (AMA),
  
• "Understanding When to Use Modifier 25" (FPM).

— Cindy Hughes, CPC, CFPC

Posted on April 28, 2023