Description:
Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
Guidelines/Instructions:
- The CPT narrative associated with this CPT modifier has changed, effective for dates of service on or after January 1, 2008
- This modifier may be used to indicate that an Evaluation and Management (E/M) service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery
- Documentation in the patient's medical record must support the use of this modifier. The CPT 2008 description for this modifier specifies that a significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M services to be reported.
- This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99281 thorugh 99285, and 99341 through 99345. These codes are 'new patient' codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed.
- No supporting documentation is required with the claim when this modifier is submitted
- A different ICD-9-CM code from the one submitted with the minor surgery is not required with the E/M code. The diagnosis for the E/M service and the other procedure may be the same or different.
- This modifier may be used to indicate that an E/M service was provided on the same day as another procedure that would normally bundle under Correct Coding Initiative (CCI). In this situation, CPT modifier 25 signifies that the E/M service was performed for a reason unrelated to the other procedure.
- Before submitting this modifier, verify whether the services are bundled through CCI. CCI edits may be updated as often as quarterly. Access the CMS Web site for the National Correct Coding Initiative on the CMS Web site.
- Code pairs identified with indicator 0 in the CCI list cannot be submitted separately for reimbursement under any circumstances. There are no exceptions to the CCI edits for indicator 0 codes
- Code pairs identified with indicator 1 may be submitted separately for reimbursement if the two services are performed in a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. Documentation must be maintained in the medical record to support the use of this modifier. No special documentation is required with the claim when CPT modifier 25 is submitted.
- Code pairs identified with indicator 9 are not subject to CCI edits. No modifier is required in these situations.
- To determine the global period of a surgery, refer to the Medicare Physician Fee Schedule database (MPFSDB)
- Access the database directly from the CMS Web site at www.cms.hhs.gov/PFSlookup/
- Select Physician Fee Schedule Search from the left area of the Web page
- Screen defaults to current year. Under Type of Information, select Payment Policy Indicators, then 'next'
- On the 'select field options' screen, select 'Next'
- Enter the procedure code and select 'All Modifiers', then click 'Submit'
- Refer to the column heading 'Global'
- 000 = Endoscopic or minor procedure with related preoperative and postoperative relative value units on the day of the procedure only, included in the fee schedule payment amount. E/M services on the same day of the procedure are generally not payable.
- 010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative values during a 10-day postoperative period included in the fee schedule amount. E/M services on the day of the procedure and during this 10-day postoperative period are generally not payable.
- 090 = Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule payment amount. E/M services on the day before the procedure, the day of the procedure, and within the 90-day postoperative period are generally not payable. For more information about E/M services on the day before or same day as a surgical procedure with 090 global days, refer to CPT modifier 57.
- MMM = Maternity codes. The usual global period does not apply.
- XXX = Global concept does not apply
- YYY = Palmetto GBA will determine whether the global concept applies and establish a postoperative period, if appropriate
- ZZZ = Code is related to another service ('add-on' code) and is always included in the global period of the other service
Additional Modifiers May Apply
When a visit occurs on the same day as a surgery with no global days, but within the global period of another surgery AND the visit is unrelated to both surgeries, it is necessary to submit CPT modifiers 25 and 24. Refer to CPT Modifier 24 on the Modifier Lookup for supporting documentation requirements that apply.
Examples for Correct use of CPT Modifier 25
Example 1: Beneficiary medical history: date of service 4/1/2008, CPT code 20610, HCPCS modifier LT (knee joint injection, 0 global days)
- On April 1, 2008, an E/M service is submitted with CPT code 99214. The patient was scheduled to receive an injection into the left knee. Due to the failure to control pain and inflammation in the left osteoarthritic knee with prior medical treatments (oral meds and joint injections), further evaluation was performed by the physician and TKR (total knee replacement) of the left knee is planned.
- Outcome: Submit CPT modifier 25 with the visit for the evaluation and planned major surgery to treat the patient’s arthritis
Example 2: Beneficiary medical history: date of service April 15, 2008, CPT code 20553 (trigger point injections, 0 global days)
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On April 15, 2008, an E/M service is submitted with CPT code 99213. The patient was evaluated for treatment of neck pain and elevated blood pressure. The trigger point injections were administered for neck pain. New meds were prescribed to control the patient's elevated blood pressure.
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Outcome: Submit CPT modifier 25 with the visit for the evaluation and treatment of the patient's elevated blood pressure
Example of Incorrect use of CPT Modifier 25
- On June 1, 2008, an E/M service is submitted with CPT code 99213 and CPT modifier 25. During the same patient encounter, the physician also debrides the skin and subcutaneous tissues (CPT code 11042, 0 global days). CPT 99213 was submitted to reflect the physician's time, examination and decision making related to determining the need for skin debridement. The physician's time was not significant and separately identifiable from the usual work associated with the surgery, and no other conditions were addressed during the encounter.
- Outcome: Do not submit the E/M service. The E/M service is not separately reimbursable from the surgical procedure. Submit only the surgical procedure (CPT code 11042).
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