The 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.
Medicare defines same physician as physicians in the same group practice who are of the same specialty. In this instance they must bill and be paid as though they were a single physician.
Modifier 25 indicates that 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.
All E/M services provided on the same day as a procedure are part of the procedure and Medicare only makes separate payment if an exception applies.
Use Modifier 25 with the appropriate level of E/M service.
An E/M service may occur on the same day as a procedure. Medicare allows payment when the documentation supports the 25 modifier.
The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File.
Modifier 25 used by a physician other than the physician performing the procedure.
Documentation shows the amount of work performed is consistent with the level of effort normally performed and is not a significant, separately identifiable E/M service.
Modifier 25 should not be reported on procedure code 99211.
Do not append the following E/M codes that are clearly for new patient only:
Note: The codes listed above are listed as new patient codes and are automatically excluded from global surgery package edit. They are reimbursed separately from surgical procedures. A modifier is not required if visit meets significant and separately identifiable guidelines.