Modifier 25: Usage and Abuse

Modifier 25 is significant identifiable evaluation and Management Service which is done by the physician on the same Date of Service

What is modifier 25  ?

Modifier 25 is significant identifiable evaluation and Management Service which is done by the physician on the same date of service so what does that mean that means when the patient is seen by the physician on the same date of service each visit should have its significance its reason and then only it is paid by the insurances accepted by the insurances and you would not be ending up getting denial from the insurance. 

Wait so does that mean if I'm billing two services for any patient for the same data service I should use modifier 25?

The answer is no. Let's understand what are the basic requirements

Here are some modifier 25 specific requirements:

1. The visit of the patient should be significant and indicates that it is Medically Necessary 

2. Both the E/M services provided should be separate and have a significant diagnosis 

3. Modifier 25 always goes with E/M code you would not add 25 to any other CPT codes 

4. Second E/M billed should have its significance its requirements and own diagnosis with the problems which indicate that It was medically necessary. 

5. In simple language, 25 modifier is only used when you are billing to E/M services for single date  of service and will only be paid by insurance if you are billing with the modifier 25 and both the visits have their significance.

6. For Example A visits doctor for hypertension issues and doctor evaluates problem and bill for E/M service. A visits again to doctor in evening for preventive routine checks in such scenario we can bill E/M with Preventive CPT Codes appending modifier 25 to E/M CPT Codes.

I hope this article helps and give clarity to your confusion. If you have any feedback you can comment below and your comments will be appreciated.

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