Modifier 25 is one of the most scrutinized modifiers by Medicare and commercial payers. It is used 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."
When to Use Modifier 25
You can only use Modifier 25 on an E/M code (e.g., 99213, 99214). It tells the payer: "Yes, I did a procedure today, but I also performed a separate medical evaluation that went above and beyond the usual pre-op/post-op care for that procedure."
| E/M Code | Modifier | Procedure Code |
|---|---|---|
| 99214 | 25 | 20610 (Joint Injection) |
Medical Necessity and Different Diagnoses
While Medicare does not strictly require a different ICD-10 diagnosis code to use Modifier 25, having a separate diagnosis makes your claim much stronger during an audit.
NCCI Edits and Modifier 25
Always run an NCCI check when billing an E/M with a procedure. If the procedure has a global period of 0 or 10 days (a "minor procedure"), the E/M will bundle into it and deny unless Modifier 25 is appended.