Modifier 25

Modifier 25 answers one question: whether the visit stood on its own. Every procedure already includes some evaluation of the patient, so when a provider performs a procedure and also bills an E/M code for the same day, the payer assumes the visit was the routine assessment that comes with the procedure and bundles it. Modifier 25 on the E/M code says otherwise: the patient’s condition required evaluation work beyond the pre- and post-procedure care that the procedure already pays for. CMS’s global surgery booklet uses it exactly this way for minor procedures, and notes that the E/M does not need a different diagnosis from the procedure.

What it does not do is excuse thin documentation. CMS expects the record to document the medically necessary E/M service and the procedure well enough to support the claim, though the documentation is not submitted with it. A payer that audits modifier 25 will ask for the note and look for a history, examination or decision-making component that is clearly distinct from the procedure work.

The mistake is habit. Some practices add 25 to every same-day E/M, which pays until a payer runs a focused review and recoups a year of visits. The opposite mistake is leaving it off a genuinely separate visit and losing the E/M to a bundling denial. Decide from the note, visit by visit, and if the only reason for the visit was the procedure, do not bill the E/M at all.