While a previous article discussed how to use modifier 59, the most commonly misused of all CPT modifiers, there are plenty more tricky culprits that can trip up unwary coders. Another one that is frequently misunderstood is modifier 25, defined as a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”
One of the biggest trip-ups that makes this code notorious is the very first word of the description: significant. This means that the second E/M service must be not only medically necessary, but also severe enough to warrant an additional procedure. Insignificant issues, such as a patient returning to ask a brief follow-up question, are not eligible for this modifier.
Additionally, the second service must qualify as a separate E/M service. The two procedures can be closely related, but they must each be distinct services with their own corresponding CPT codes. As CareCloud states in the following example, a patient who presents for occasional chest discomfort would require one code for the initial E/M visit, and a second code for the cardiovascular stress test that the physician orders for later that day. In this case, modifier 25 would be added to the initial, primary E/M code to denote that a second service was also performed.
This does not, however, mean that the additional procedure must take place during a completely separate encounter. It is perfectly acceptable to use modifier 25 for two services rendered hours apart as long as they are still within the same day and administered by the same provider.
Finally, be careful not to use modifier 25 for certain services that are already included in previous codes. For example, additional procedures performed during the postoperative period of a surgery are not eligible for this modifier as long as the further services are directly related to the initial surgery.