Modifier 25 Documentation and Examples
Under Medicare guidance, modifier 25 goes on the evaluation and management (E/M) claim line when the same physician or qualified practitioner provides another procedure or service to the same patient that day. The record must support a medically necessary, significant and separately identifiable E/M service beyond the care routinely included in the other service.
What should the record show?
- Which concern the clinician evaluated and how they assessed or managed it.
- What work supported the E/M service beyond the usual work of the other service.
- Enough detail to support the E/M level billed and to identify the E/M line on the claim.
A different diagnosis is not required by Medicare solely because modifier 25 is used. A second diagnosis by itself does not establish that the visit involved separate work.
Illustrative example
During a visit for a minor skin procedure, the clinician also evaluates worsening asthma symptoms and documents a change to the treatment plan. The asthma evaluation may support a separately reported E/M service if the record supports the billed level. Reviewing the lesion and discussing routine wound care alone are part of the procedure work.
Modifier 25 vs. modifier 59
Modifier 25 describes a separate E/M service. Modifier 59 describes why a non-E/M service is distinct from another service under the applicable edit rules. Medicare includes the decision to perform a minor surgery in the procedure payment, for both new and established patients. For a same-day denial, check the submitted line and the documentation before changing the modifier.
Sources and payer scope
These examples are educational and use Medicare guidance. For a specific claim, check the payer’s policy and the rules in effect on the date of service.