How to Use Modifier 25

What needs to be documented?

• Documentation must demonstrate the medical necessity of the E/M service.
• If possible, physically separate the documentation for the preventive service or procedure from the documentation for the problem-oriented E/M service within the patient’s medical record. 
• Documentation should be able to support each service (i.e., the preventive service or procedure and the E/M) as though it were a standalone service.

Are separate diagnoses required?

No. An E/M service may be reported if it is clinically indicated and reflects work that is above and beyond the preoperative work associated with the procedure — even if both services have the same diagnosis. An example would be a patient who presents with a head laceration and you examine the patient for neurological damage before repairing the laceration.

Is modifier 25 required for E/M services provided at the same encounter as vaccines?

Yes and no. Traditional Medicare does not require modifier 25 for E/M services provided in conjunction with administration of the influenza (Healthcare Common Procedure Coding System [HCPCS] G0008), pneumococcal (HCPCS G0009) or hepatitis B (HCPCS G0010) vaccines. Medicare does require modifier 25 for E/M services provided in conjunction with other vaccine administration codes, including CPT codes 90480, 90460, 90461, 90471, 90472, 90473 and 90474. Private payers may have different policies. The E/M service must be significant and separately identifiable from the vaccine administration. 

Can a preventive medicine visit and a problem-oriented visit be billed in the same encounter?

Yes. If a patient presents for a preventive visit and the physician identifies a new problem or changes to an existing problem that are significant enough to require additional work to perform the key components of the problem-oriented E/M service, both the preventive service and the appropriate office/outpatient E/M service may be reported. Append modifier 25 to the office/outpatient E/M service. While preventive and wellness services are not subject to cost-sharing, the office/outpatient E/M service may be subject to deductible and cost-sharing. If the problem is trivial and does not require additional work, an office/outpatient E/M service should not be reported.

For more information and examples, review the FPM article “Combining a Wellness Visit with a Problem-Oriented Visit: a Coding Guide.” 

Do all payers follow the same rules for modifier 25?

Not necessarily. Traditional Medicare adheres to the National Correct Coding Initiative (NCCI). NCCI edits are updated quarterly. Some Medicare Administrative Contractors have NCCI Lookup tools available (Novitas, CGS Medicare, First Coast Service Options, Palmetto).  Private payers often use their own claims editing systems and may not always align with Medicare. Review your payers’ policies or contact your local provider relations representative for more information.  

How is the new add-on HCPCS code G2211 impacted by modifier 25?

As of January 1, 2024, Medicare implemented a new HCPCS code G2211 to reflect the visit complexity associated with providing comprehensive, longitudinal care. 

As part of the implementation of the new HCPCS code G2211, the Centers for Medicare & Medicaid Services (CMS) instituted a policy that prohibits its use when the office/outpatient E/M service is appended with modifier 25. Medicare will not pay for HCPCS code G2211 when modifier 25 is appended to the office/outpatient E/M service. 

The AAFP believes this policy is contrary to the intent of the code and is advocating with CMS to change its policy. However, in the interim, Medicare will deny the G2211 line item on a claim if an E/M with a 25 modifier is also reported on the same date. You can read more about the AAFP’s advocacy efforts here. Additional information about G2211 is available on the webpage “G2211 Add-on Code: What It Is and When To Use It.”

Where can I find more information about modifier 25? 

You can find additional information, tools, and tips from the AAFP and the AMA.

• FPM Getting Paid blog: Seven quick tips for using modifier 25 (April 2023)
• FPM article: Combining a Wellness Visit With a Problem-Oriented Visit: a Coding Guide (January/February 2022)
• FPM article: Understanding when to use Modifier -25 (October 2004)
• FPM article: Getting Paid for Screening and Assessment Services (November/December 2017)
• AMA: Setting the record straight on proper use of modifier 25
• AMA CPT® Assistant: Reporting CPT Modifier 25
• CMS Medicare Claims Processing Manual, Chapter 12  and General Correct Coding Policies, Chapter 1.