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.
Q: Sally, a 9-year-old girl presents for her yearly physical with her pediatrician. At the time of the visit, she complains of watery eyes, scratchy throat, and stuffy nose for the past three days. The provider performs the physical. He also performs a history and exam and treats the patient for a URI with low medical decision-making. What CPT coding is reported for this visit?
A: 99393, 99213-25. Rationale: In addition to the yearly physical, the pediatrician also evaluates and treats the URI. The additional work for the URI allows the reporting of an established patient office visit. Modifier 25 is appended to the office visit to show it is a significant and separately identifiable service from the preventive visit.
Reference: FY 2023 CPT codebook, 2023 AMA Evaluation and Management Guidelines
