Medicare Part – B Modifier -25

Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service: The physician may need 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 that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service.

Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed with the 25 modifier in addition to billing for suturing a scalp wound if a full neurological examination was made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status. In the circumstance when the decision to perform a minor procedure is typically done immediately before the service, (e.g., whether or not sutures are needed to close a wound, whether or not to remove a mole or wart, etc.) it is considered a routine preoperative service and a visit or consultation should not be reported in addition
to the procedure.

Separate payment may be made for an initial hospital visit (CPT codes 99221-99223), an initial inpatient consultation (CPT codes 99251-99255) and a hospital discharge service (CPT codes 99238 and 99239) when billed by the same physician for the same date as an inpatient dialysis service (CPT codes 90935-90947). It is no longer required that these evaluation and management services be unrelated to the treatment of the patient’s ESRD in order for payment to be made. However, the 25 modifier must still be reported with these evaluation and management services in order to indicate that they are significant and separately identifiable services. Physicians may request reviews of previously denied services.