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Modifier 25 fact sheet

Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service. 

Physicians of the same specialty in the same group practice are considered the same physician; therefore, they must bill and be paid as though they were a single physician.

Appropriate use

Use modifier 25 with the appropriate level of E/M service.

  • Modifier 25 indicates on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre-and post-operative care associated with the procedure or service performed.
  • E/M service may occur on the same day as a procedure. Medicare allows payment when the documentation supports modifier 25.
  • The minor surgical procedure performed has a global period of 0 days or 10 days listed on the Medicare physician fee schedule and meets the definition of modifier 25.

Global surgery 

Global surgery is defined as all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty.

Do not use modifier 25 when billing for services performed during a postoperative period if related to the previous surgery. Related, follow-up examinations by the same provider during the global period of a previous procedure are included in that procedure’s global surgical package.

  • For an unrelated E/M service during the global period of a previous procedure, you may be able to report an appropriate E/M code with modifier 24(unrelated evaluation and management service by the same physician during a postoperative period) appended.
    • The E/M is for a new problem not related to the patient’s previous complaint or procedure.
  • Append modifier 57 (decision for surgery) rather than modifier 25 if the E/M service prompts the decision to render a major procedure within 24 hours of the E/M service. Major procedure is defined as one with a 90-day global period.

National correct coding initiative (NCCI) procedure to procedure (PTP) edits

The NCCI promotes national correct coding methodologies and controls improper coding leading to inappropriate payment. The PTP code pair edits are automated prepayment edits preventing improper payment when reporting certain codes together for Part B-covered services on the same day by the same physician. 

When both correct coding and global surgery edits apply to the same claim by the same physician, we’ll first apply the correct coding edits. Then, we’ll apply the global surgery edits to the correctly coded services.

References

E/M visit complexity add-on HCPCS code G2211

Effective for dates of service on and after January 1, 2025:

  • HCPCS code G2211 is payable when an associated office and outpatient (O/O) E/M base code (CPT codes 99202-99205 or 99211-99215) is reported with modifier 25 for the same patient by the same provider and a Part B preventive service, immunization administration, or annual wellness visit service identified in attachment 1 in Change Request (CR) 13705 is also present for the same date of service.

For claims not containing one of the identified services above or dates of service prior to January 1, 2025:

  • Claims will deny when HCPCS code G2211 and an associated office and outpatient (O/O) E/M visit (CPT codes 99202-99205 or 99211-99215) is reported with modifier 25 for the same patient by the same provider on the same date of service:
    • Separately identifiable visits occurring on the same day as minor procedures (such as 0 or 10-day global procedures) have resources sufficiently distinct from costs associated with furnishing stand-alone O/O E/M visits to justify different payment.

References:

Inappropriate use

  • Do not report HCPCS code G2211 when modifier 25 is reported on an associated O/O E/M visit (CPT codes 99202-99205 and 99211-99215) for claims not containing a Part B preventive service, immunization administration, or annual wellness visit service or dates of service prior to January 1, 2025.
  • Do not use modifier 25 with CPT code 99211.
  • Do not use modifier 25 for a physician other than the physician performing the procedure or physician of the same specialty in the same group practice.
  • Do not use modifier 25 when documentation does not support a significant, separately identifiable E/M service.

References