Using Modifier 25 in Medical Billing

When claims require modifier 25, there are some simple tips you can use to know the modifier’s details, such as which code to append it to, as well as when to use the modifier.

It is important to identify the claim makeup in order to solve the problem of which code to use modifier 25 with. Modifier 25 is a significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service. Do you attach modifier 25 to the well visit or to the sick code? Modifier 25 can be applicable on either code. Therefore, the answer depends on the claim makeup.

2. Put 25 on Problem E/M Following Well

You should put modifier 25 on the problem E/M following well when the encounter meets the following criteria:
-the pediatrician provides a sick and preventative visit at the same time
-the preventative visit was the reason for the scheduled visit

The reason for this is that the pediatrician has provided the sick service secondary to the preventative services. Because of this, the modifier 25 goes on to the sick visit in order to indicate that the problem is significant and separate from the preventative services.

You should charge the sick visit (in addition to the preventative medicine) only under the following conditions:

-When the physician performs a separate E/M service
-Documentation for the problem portion is separate from the preventative service
-The encounter involves a separate and distinct problem. This is determined when the problem involves treatment with a prescription, when the problem would have required a return visit had it not been addressed at this visit, and when you have a separate and distinct ICD-9 diagnosis code for the problem.

You should use modifier 25 when well visits result in a procedure. This indicates that the well visit is separately identifiable. Follow the payer policy for E/M and screening.

View all Articles by: Kathryn E, CCS-P - Retired