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ARS Position Statement: Use of Modifier -25

January 2022

The American Rhinologic Society (ARS) supports the use of modifier 25 to report a significant, separately identifiable evaluation and management (E&M) service by the same physician on the same day of a procedure or other service. By facilitating the provision of medically necessary care, modifier 25 supports prompt diagnosis and streamlined treatment, which in turn promotes efficient, high- quality, and patient-centric care.

Performing an E&M service along with a procedure (i.e. nasal endoscopy, nasal endoscopy with debridement, flexible laryngoscopy, excision of lesion, biopsy, removal of a foreign body, or control of epistaxis) is often medically necessary.  The services were valued to ensure no duplication of work or costs exists, as such both services should be reimbursed accordingly.  

References 

  1. American Medical Association. CPT 2022 Professional Edition. American Medical Association; 2021.
  2. American Medical Association. AMA/Specialty Society RVS Update Process RUC Recommendations for CPT 2022. January 2021. Accessed December 9, 2021. 
  3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. 100-04. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912. Accessed December 9, 2021. 

Below is text directly from the AMA CPT definition of Modifier 25 and the Medicare Carriers Manual regarding Modifier 25. 

AMA Current Procedural Terminology (CPT) definition of Modifier 25

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:

It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required 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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.

Medicare Carriers Manual 100-04 30.6.6.B

Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. A/B MACs (B) pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.