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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
03.00.06z

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 healthcare 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)

See Attachments A and B.
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

Policy History

Revisions From​ 03.00.06​z:
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​ 03.00.06y:
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​ 03.00.06x:
10/02/2023​​This version of the policy will become effective 10/02/2023​.

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​ 03.00.06w:
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 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​ 03.00.06v:
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​ 03.00.06u:
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​ 03.00.06t:
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, 30468, 32408, 33741, 33745, 33995, 33997, 69705, 69706, and 99417

The following CPT code have been deleted from this policy:
32405, 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 03.00.06s:
07/01/2020This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2020.

The following CPT codes have been added to this policy: 11981, 11982, 11983, 33016, 33017, 33018, 33019, 37765, 37766, 49013, 49014, 62328, 62329, 64451, 64454, 64624, 64625, 90912, 92992, 92993

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

Revisions From 03.00.6r:
04/15/2020This policy update becomes effective 4/15/2020. The policy update continues the Company's continuing position on modifier 25. This policy is being updated to convey that consultations codes will no longer be reimbursed.

Revisions From 03.00.06q:
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 03.00.06p:
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT & HCPCS codes have been added to this policy: 11981, 11982, 11983,
33016, 37765, 37766
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 03.00.06o:
01/21/2018This 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

Effective 10/05/2017 this policy has been updated to the new policy template format.
1/2/2024
1/9/2024
03.00.06
Claim Payment Policy Bulletin
Commercial
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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.