BlueCross BlueShield of South Carolina

The -25 Modifier

December 30, 2009

What Does It Mean?

The -25 modifier indicates a significant, separately identifiable evaluation and management (E/M) service by the same doctor on the same day as another procedure/service. The E/M service must be beyond the other service the doctor provided or beyond the usual preoperative or postoperative care associated with the procedure.
 
We do not require different diagnoses for reporting the E/M service on the same date, but both services should be distinct. Report the E/M service by appending a modifier -25 to the E/M code.

When to Use the -25 Modifier

If you are seeing a patient for one condition, but the patient presents a totally different problem that you must also address during the visit. Or, the condition for which you were providing the original service may prompt the E/M service. Here are some examples:

• A child comes to a pediatrician’s office for a well-child visit but also complains of a sore throat. Since the pediatrician is seeing the child for a well-child checkup, he or she should append the -25 modifier to the E/M code that applies to the sick visit.
• An orthopaedic surgeon sees a patient for knee pain and administers an injection. While there, however, the patient also complains of wrist pain that is associated with carpal tunnel syndrome. The surgeon should append modifier -25 to the E/M code.

Tips on Appropriate Use of Modifier -25

• Be sure to report both a procedure code and an E/M code on the claim.
• Attach the -25 modifier to the E/M code (99201-99499). Do not add a -25 modifier to surgery, radiology, laboratory, injections, diagnostic codes, etc.
• Be sure to clearly document both the procedures and the E/M services in the patient’s records.