CPT Modifier 25

Description
CPT modifier 25 is used for significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

Guidelines and Instructions

• This modifier may be used to indicate that an evaluation and management (E/M) service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery
• Documentation in the patient's medical record must support the use of this modifier. No supporting documentation is required with the claim when this modifier is submitted.
• New patient codes (e.g., CPT codes 92002, 92004, 99201–99205) are automatically excluded from the global surgery requirements and would not normally require CPT modifier 25 to be separately reimbursed from a surgical procedure
  • Exceptions (not all inclusive):
    • If the new patient code and surgical procedure is a National Correct Coding Initiative (NCCI) combination, CPT modifier 25 might be required  
• A different diagnosis code from the one submitted with the minor surgery is not required with the E/M code. The diagnosis for the E/M service and the other procedure may be the same or different.
• To determine the global period of a surgery, refer to the Medicare Physician Fee Schedule database (MPFSDB)
• Access the database directly from the CMS website
  • Select Physician Fee Schedule Search from the bottom of the web page
  • Screen defaults to current year. Under Type of Information, select Payment Policy Indicators.
  • Choose a single procedure code, multiple procedure codes or a range of codes, then enter the appropriate code(s)
  • Select modifier (or select "all modifiers")
  • Select Submit
  • Refer to the column heading "Global"
  • 000 corresponds to an endoscopic or minor procedure with related preoperative and postoperative relative value units on the day of the procedure only, included in the fee schedule payment amount. E/M services on the same day of the procedure are generally not payable.
  • 010 corresponds to a minor procedure with preoperative relative values on the day of the procedure and postoperative values during a 10-day postoperative period included in the fee schedule amount. E/M services on the day of the procedure and during this 10-day postoperative period are generally not payable.
  • 090 corresponds to a major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule payment amount. E/M services on the day before the procedure, the day of the procedure and within the 90-day postoperative period are generally not payable. For more information about E/M services on the day before or same day as a surgical procedure with 090 global days, refer to CPT modifier 57.
  • MMM corresponds to maternity codes. The usual global period does not apply.
  • XXX corresponds to global concept does not apply
  • YYY corresponds to Palmetto GBA will determine whether the global concept applies and establish a postoperative period, if appropriate
  • ZZZ corresponds to code is related to another service ('add-on' code) and is always included in the global period of the other service

Examples for Correct Use of CPT Modifier 25
Example 1: Beneficiary medical history: date of service January 3, CPT code 20610, HCPCS modifier LT (knee joint injection, 0 global days).

• On January 3, an E/M service is submitted with CPT code 99214. The patient was scheduled to receive an injection into the left knee. Due to the failure to control pain and inflammation in the left osteoarthritic knee with prior medical treatments (oral meds and joint injections), further evaluation (additional assessment and intervention) was performed by the physician and TKR (total knee replacement) of the left knee is planned.
• Outcome: Submit CPT modifier 25 with the visit for the evaluation and planned major surgery to treat the patient’s arthritis

Example 2: Beneficiary medical history: date of service February 15, CPT code 20553 (trigger point injections, 0 global days).

• On February 15, an E/M service is submitted with CPT code 99213. The patient was evaluated for treatment of neck pain and elevated blood pressure. The trigger point injections were administered for neck pain. New meds were prescribed to control the patient's elevated blood pressure.
• Outcome: Submit CPT modifier 25 with the visit for the evaluation and treatment of the patient's elevated blood pressure

Example of Incorrect Use of CPT Modifier 25

• On January 24, an E/M service is submitted with CPT code 99213 and CPT modifier 25. During the same patient encounter, the physician also debrides the skin and subcutaneous tissues (CPT code 11042, 0 global days). CPT 99213 was submitted to reflect the physician's time, examination and decision making related to determining the need for skin debridement. The physician's time was not significant and separately identifiable from the usual work associated with the surgery, and no other conditions were addressed during the encounter.
• Outcome: Do not submit the E/M service. The E/M service is not separately reimbursable from the surgical procedure. Submit only the surgical procedure (CPT code 11042).

References

• CMS Internet-Only Manual Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2–40.5 (PDF, 1.1 MB)
• CMS Internet-Only Manual Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, Addendum at the end of the chapter (PDF, 699 KB)