Cracking the Code
Coding Modifier 25
Modifiers are added to CPT and HCPCS Level II codes to report such items as changes to a procedure, a service, or medical equipment without changing the definition of the code. Modifiers are two characters which can be letters or numbers.
Modifier 25 is defined as “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Healthcare Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed.”
A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The 2023 AMA Evaluation and Management Guidelines break down how E/M services are defined.
Modifier 25 would not be appended during a postoperative period of related to the previous surgery. This modifier would also not be used when a minimal procedure is performed on the same day unless a level of service can be supported as significant, separately identifiable. All procedures have an “inherent” E/M service included.