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Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
MA03.003n

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

This policy applies to professional and outpatient facility claims​.

When an evaluation and management (E&M) service is performed on the same day, by the same professional provider or qualified professional provider as a procedure or other service​, because the individual's condition or symptoms require a significant, separately identifiable E&M service, the E&M service should be appended with modifier 25 to indicate that the E&M is not part of the global surgical package and is therefore eligible for reimbursement consideration by the Company.

It is appropriate to append modifier 25 to an E&M service in the following circumstances:
  • The E&M service is a significant and separately identifiable service performed by the same professional provider or qualified professional provider on the same day of the procedure or other service.
    • Different diagnoses are not required for reporting E&M services on the same day as a procedure or other service.
  • The E&M service is performed by the same professional provider or qualified professional provider on the day of a minor procedure.
    • A minor procedure has a zero-day or 10-day postoperative period.
  • The E&M service is beyond the usual preoperative and postoperative care associated with the procedure or other service.
  • The problem-focused E&M service is performed at the same time as a preventive care visit.
  • The E&M service is reported with preoperative critical care codes within a global surgical period.
It is inappropriate to append modifier 25 to an E&M service in the following circumstances:
  • The initial decision to perform a major procedure is made during an E&M service that occurs on the day before or the day of a major procedure.
    • A major procedure has a 90-day postoperative period.
    • Modifier 57 (decision for surgery) should be used in this instance.
  • The E&M service is reported by a professional provider or qualified professional provider other than the professional provider or other qualified professional provider who performed the procedure.
  • The E&M service is performed on a different day than the procedure.
  • The modifier is reported with an E&M service that is within the usual preoperative or postoperative care associated with the procedure.
  • The modifier is reported with a non-E&M service.
  • The reason for the office visit was strictly for the minor procedure because reimbursement for the procedure includes the related preoperative and postoperative service.
  • The professional provider performs ventilation management in addition to an E&M service.
  • The preventive E&M service is performed at the same time as a preventive care visit (e.g., a preventive E&M service and a routine gynecological exam performed on the same date of service and by the same professional provider or qualified professional provider​). Because both represent preventive visits, only one should be reported.
  • The routine or serial use of the modifier is reported without supporting clinical documentation.

​​When modifier 25 is appropriately appended to an E&M service and is submitted on the same date of service, by the same professional provider or other qualified healthcare provider, as a minor procedure, the E&M service is reimbursed at 50 percent of the applicable fee schedule amount.

  • Refer to Attachment A for a list of the specific problem-focused E&M codes and minor procedure codes.

When modifier 25 is appropriately appended to a problem-focused E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M, the problem-focused E&M service is reimbursed at 50 percent of the applicable fee schedule amount.

  • Refer to Attachment B for a list of the specific problem-focused E&M codes and preventive E&M codes.​
REQUIRED DOCUMENTATION

When appending modifier 25 to an E&M service billed on the same date of service as a procedure or other service, documentation for the additional E&M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E&M service. The documentation should be clearly distinct from the documentation related to the procedure performed on the same date of service. The additional E&M service must be able to stand alone as a billable service with no overlapping of key E&M components (medical history, medical examination, and medical decision-making performed). The record must include documentation for all services provided on the specific date of service. The record should not include any documentation from previous dates of service (i.e., cloning), unless related to the specific date of service being reported.

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct pre-payment reviews and ​post-payment audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

The company requires that professional providers or qualified professional provider report on one CMS-1500 claim form or the electronic equivalent, 837p when two or more procedures or services were performed for the same patient, by the same professional provider or other qualified healthcare provider, and on the same date of service.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

Guidelines

This policy is consistent with Medicare's reporting requirements. The Company's payment methodology may differ from Medicare.

Description

In certain instances, it may be necessary for professional providers or other qualified healthcare providers to perform an evaluation and management (E&M) service on the same day that a procedure or other service is performed. When an individual's condition or symptoms require a significant, separately identifiable E&M service above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure that was performed on that day, the E&M service should be appended with modifier 25.

As defined by the Centers for Medicare & Medicaid Services (CMS) and applied by the Company, reimbursement for a surgical procedure includes a standard global surgical package, which includes preoperative, intraoperative, and postoperative services.

References

American Medical Association (AMA). CPT® 2018 Professional Edition: Spiralbound.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician Practitioners. §30.6.6. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf​. Accessed October 13, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network. Global Surgery Fact Sheet. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GloballSurgery-ICN907166.pdf.

Novitas Solutions. Modifier 25 Fact Sheet. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00097341. Accessed November 19, 2021.

Optum360. 2018 Understanding Modifiers: Softbound.

Coding

CPT Procedure Code Number(s)
See Attachments A and B.​
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A

Modifiers

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service​

Coding and Billing Requirements

BILLING REQUIREMENTS

The company requires that professional providers or other qualified healthcare providers report on one CMS-1500 claim form or the electronic equivalent, 837p when two or more procedures or services were performed for the same patient, by the same professional provider or other qualified healthcare provider, and on the same date of service.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

Policy History

Revisions From​ MA03.003n:
01/02/2024
This policy has been identified and updated for the CPT/HCPCS code update effective 01/02/2024.

​The following CPT/HCPCS codes have been added to attachment A of this policy:
31242, 31243, 52284, 58580, 64596, 64598, and 67516

The following CPT/HCPCS codes and have had narrative revisions in attachment A of this policy:
63685, 63688, 64590, 64595, 96920, 96921, 96922, 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215

The following CPT/HCPCS codes have had narrative revisions in attachment A of this policy:
​99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215

The following CPT/HCPCS code has been removed from attachment A of this policy:
0499T​

Revisions From​ MA03.003m:
​01/01/2024
​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​
10/01/202​3
This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2023.

Procedure code 0780T has been added to attachment A of this policy:

​​The following CPT/HCPCS codes have been removed from attachment A of this policy:
D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2753, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2961, D2962, D3120, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, D3357, D3410, D3421, D3425, D3426, D3428, D3429, D3999, D4341, D4342, D7410, D7471, D7472, D7473, D7485, D7490, D7510, D7511, D7520, D7521, D7530, D7540, D7550, D7560, D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7871, D7872, D7873, D7874, D7875, D7876, D7877, D7899, D7946, D7947, D7948, D7949, D7950, D7951, D7952, D7953, D7955, D7956, and D7957​

Revisions From​ MA03.003l:​
06/12/2023​​​This version of the policy will become effective 6/12/2023​.

CPT code 99211 has been removed from this policy. The company's position has been revised. Procedure code 99211 is no longer eligible to be reported with Modifier -25.

Minor surgery procedure code 11982 has been added to the policy in attachment A as a minor surgery when reported with modifier -25 on the same day as an eligible E/M service will be reduced by 50%. 

CPT code 11983 has undergone a narrative revision in attachment A​.​

Revisions From​ MA03.003k:
01/01/2023
This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2023.

​The following CPT/HCPCS codes have been added to attachment A of this policy:
99418, G0316, G0317, G0318, D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2753, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2961, D2962, D3120, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, D3357, D3410, D3421, D3425, D3426, D3428, D3429, D3999, D4341, D4342, D7410, D7471, D7472, D7473, D7485, D7490, D7510, D7511, D7520, D7521, D7530, D7540, D7550, D7560, D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7871, D7872, D7873, D7874, D7875, D7876, D7877, D7899, D7946, D7947, D7948, D7949, D7950, D7951, D7952, D7953, D7955, D7956, D7957, 15778, 30469, 33900, 33901, 33902, 33903, 36836, 36837, 43290, 43291, 49591, 49592, 49593, 49594, 49595, 49596, 49613, 49614, 49615, 49616, 49617, 49618, 49621, and 49622 ​

The following CPT/HCPCS codes and have been had narrative revisions in attachment A of this policy:
64415, 64416, 64417, 64445, 64446, 64447, 64448, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99417, and G2212

The following CPT/HCPCS codes have been removed from attachment A of this policy:
99217, 99218, 99219, 99220, 99224, 99225, 99226, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99343, and 0491T

Revisions From​ MA03.003j:
01/01/2022
This version of the policy will become effective​ 01/01/2022. The intent of this policy remiains unchanged, but has the policy has been updated to clarify coverage criteria and Required Documentation of claims submitted with modifier 25.
__________________________________________________________________
This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2022.

​The following CPT codes have been added to attachment A of this policy:
28003, 33894, 33895, 33897, 42975, 53451, 53452, 53453, 53454, 61736, 61737, 64628, 67141, 67145, 68841, 93593, 93594, 93595, 93596, and 93597

The following CPT codes and have been had narrative revisions in attachment A of this policy:
11981, 21315, 21320, 93653, 93654, and 93656​

CPT code 99211 has had a narrative revision in attachment A and B of this policy.

CPT codes have been removed from attachment A of this policy:
21310, 93530, 93531, 93532, and 93533

Revisions From ​MA03.003i:
07/01/2021This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2021.

The following CPT and HCPCS codes have been added to this policy:
0446T, 0447T, 0448T, 28820, 28825, 33990, 33991, 33992, and 33993

HCPCS code G0460​ has been removed from this policy.

Revisions From ​MA03.003h:
01/01/2021This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021.

The following CPT and HCPCS codes have been added to this policy: 
G2211, G2212, 11981, 11982, 11983, 33016, 30468​, 32408, 33017, 33018, 33019, 33741, 33745, 33995, 33997, 37765, 37766, 49013, 49014, 62328, 62329, 64451, 64454, 64624, 64625, 69705, 69706,​ 90912​ and 99417

The following CPT code have been deleted from this policy:
32405, 33010, 33011, ​64402, 64410, 64413, 64421, 90911, 92992, 92993, and 99201

The following CPT code narratives have been revised in this policy: 
64455, 64479, 64483, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215​​

Revisions From MA03.003g:
01/01/2020This version of the policy will become effective 01/01/2020.

The following CPT & HCPCS codes have been added to this policy: 33016, 37765, 37766, 33017, 33018, 33019, 49013, 49014, 62328, 62329, 64451, 64454, 64624, 64625, 90912, 92992, 92993

The following CPT codes have been deleted from this policy: 33010, 33011, 34812, 64402, 64410, 64413, 64421, 90911

The following CPT code narratives have been revised in this policy: 31233, 31235, 31292, 31293, 31294, 31295, 31296, 31297, 31298, 62270, 62272, 64400, 64405, 64408, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450

Revisions From MA03.003f:
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT & HCPCS codes have been added to this policy: G0460, 11102, 11104, 11106, 27369, 33285, 33286, 33289, 36572, 36573, 43762, 43763, 50436, 50437.

The following CPT codes have been deleted from this policy: 11100, 20005, 27370, 43760, 50395, 64508, 64550, 34812, 34820, 34833, 34834, 93561, 93562.

The following CPT code narratives have been revised in this policy: 36568, 36569, 36584.

Revisions From MA03.003e:
08/01/2018This policy will become effective 08/01/2018. This policy was revised to remove the following CPT codes: 99241, 99242, 99243, 99244, 99245.

Revisions From MA03.003d:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018. The References were updated accordingly.

The following minor procedure CPT codes have been added to Attachment A of this policy: G0516, G0517, G0518, 0479T, 0481T, 0483T, 0484T, 0489T, 0490T, 0491T, 0499T, 30140, 31241, 31253, 31257, 31259, 31298, 32994, 36215, 36216, 36217, 36465, 36466, 36482, 38573, 55874, 96573, 96574

The following minor procedure CPT codes have been deleted from Attachment A of this policy: 29582, 29583, 36515, 55450, 64565

The following CPT code narratives have been revised from Attachment A of this policy:
17250, 31254, 31255, 31276, 31645, 31646, 32998, 34812, 34820, 34833, 34834, 36468, 36470, 36471, 36516, 64550, 99217, 99218, 99219, 99220

Revisions From MA03.003c:
08/01/2017Revised policy number 03.00.06n was issued as a result of annual policy review, effective 08/01/2017. The References were updated accordingly. The policy was updated to be consistent with current template wording and format. The adoptable source for this policy is CMS.

The following language was added to the Policy section of this policy:

This policy applies to professional providers or other qualified health care providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

When an evaluation and management (E&M) service is performed on the same day, by the same professional provider or other qualified health care provider that a procedure or other service is performed because the individual's condition or symptoms require a significant, separately identifiable E&M service, the E&M service should be appended with modifier 25.
  • When modifier 25 is appropriately appended to an E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure, the E&M service is reimbursed at 50 percent of the applicable fee schedule amount.
    • A minor procedure has a zero-day or 10-day postoperative period.
    • Procedures without a zero-day or 10-day postoperative period (e.g. Immunizations and vaccines, and their associated administration services, as well as EKGs and pulmonary function testing, etc.) are not considered minor procedures and are not subject to the 50 percent reduction of this policy.
    • Refer to Attachment A for a list of the specific problem-focused E&M codes and minor procedure codes.
  • When modifier 25 is appropriately appended to a problem-focused E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M, the problem-focused E&M service is reimbursed at 50 percent of the applicable fee schedule amount.
    • Refer to Attachment B for a list of the specific problem-focused E&M codes and preventive E&M codes.
REQUIRED DOCUMENTATION

When appending modifier 25 to an E&M service billed on the same date of service as a procedure or other service, documentation for the additional E&M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E&M service. The documentation should be clearly distinct from the documentation related to the procedure performed on the same date of service. The additional E&M service must be able to stand alone as a billable service with no overlapping of key E&M components (medical history, medical examination, and medical decision-making performed). The record must include documentation for all services provided on the specific date of service. The record should not include any documentation from previous dates of service (i.e. coning), unless related to the specific date of service being reported.
BILLING REQUIREMENTS

The company requires that professional providers or other qualified health care providers report on one CMS-1500 claim form or the electronic equivalent, 837p when two or more procedures or services were performed for the same patient, by the same professional provider or other qualified health care provider, and on the same date of service.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

The following language was removed from this policy:

MEDICARE

This policy is consistent with Medicare's reporting requirements. The Company's payment methodology may differ from Medicare.

The following codes were removed from the CPT Procedure Code Number(s) and Narrative(s) section of this policy:

0188T 0189T 0359T 0360T 0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T 0369T 0370T 0371T 0372T 0373T 0374T 34839 92002 92004 92012 92014 96160 99024 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99224 99225 99226 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99281 99282 99283 99284 99285 99288 99291 99292 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99339 99340 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99355 99356 99357 99358 99359 99360 99363 99364 99366 99367 99368 99374 99375 99377 99378 99379 99380 99381 99382 99383 99384 99385 99386 99387 99391 99392 99393 99394 99395 99396 99397 99401 99402 99403 99404 99406 99407 99408 99409 99411 99412 99429 99441 99442 99443 99444 99446,99447,99448,99449,99450 99455 99456 99460 99461 99462 99463 99464 99465 99466 99467 99468 99469 99471 99472 99475 99476 99477 99478 99479 99480 99485 99486 99487 99489 99490 99495 99496 99497 99498 99499

The following codes were removed from the HCPCS Level II Code Number(s) and Narrative(s) section of this policy:

D9311 G0101 G0102 G0128 G0175 G0181 G0182 G0245 G0246 G0247 G0337 G0378 G0379 G0380 G0381 G0382 G0383 G0384 G0402 G0406 G0407 G0408 G0425 G0426 G0427 G0436 G0437 G0438 G0439 G0463 G0473 G0501 G0505 G0506 G0508 G0509 G9050 G9051 G9052 G9053 G9054 G9055 S0260 S0265 S0601 S0610 S0612 S0613 S9117 S9123 S9124 S9140 S9141 S9455

The following codes were added to Attachment A of this policy:

92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, G0101, G0402, G0463, S0610, S0612, S0613, G0438, G0439, G0380, G0381, G0382, G0383, G0384
The following codes were added to Attachment B of this policy:

Problem-Focused E&M Codes

99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, G0463

Preventive E&M Codes

99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, G0402, G0438, G0439

Revisions From MA03.003b:
01/01/2017This is a a coding update policy.

Revisions From MA03.003a:
01/21/2015This is a a coding update policy.

Revisions From MA03.003:
01/01/2015This is a new policy.
1/2/2024
1/9/2024
MA03.003
Claim Payment Policy Bulletin
Medicare Advantage
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.