Is Your Medical Biller Using Modifier 25?

To understand modifier 25, let’s define what it is.  Modifier 25 is Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

This modifier can only be used with an Evaluation and Management service.  It has to be above and beyond the usual preoperative and postoperative encounter with the procedure.  Using this modifier does not require you to use another diagnosis to bill.  It is most important that the Evaluation and Management level should meet its key components.  Make sure that when using this modifier that it meets medical necessity.  Below is an example of when this modifier would be used.

A patient comes in for a follow up for chronic neck pain, and then the patient then complains of having severe allergies.  A pain management procedure was administered at the same time of service.  This would call for the modifier 25 being used for the Evaluation and Management code to indicate that both services were rendered on the same day.

It is important that a medical insurance biller use this code when appropriate.  Otherwise you will receive many claims that will have unpaid codes that could have been paid for.  Keeping up to date on changes with this modifier is important to ensure efficiency when billing.

An example of not using modifier 25 is when an ear nose and throat physician has seen a patient with Medicare, for a routine office visit and the physician decides that the patient needs a hearing test which can be done in their office by a certified Audiologist.  The physician determines that the patient has hearing loss from the results of the hearing test.  The physician now can bill for an office visit, most likely a 99213 or 99214 and a hearing test, which is a procedure using CPT code 92557.  Now if the modifier 25 was not attached to the Evaluation and Management code, the hearing test 92557 would not receive payment.  So if the E/M code has the modifier 25 billed along with it and then the procedure code for the hearing test 92557 both will be paid.

So many physicians have missed out on payment of minor procedures or testing performed in the office because of the fact that the biller did not attach the modifier 25 to the Evaluation and Management code.  What a costly mistake for the physician.  Some insurance companies may allow you to re-bill a corrected claim to re-submit for payment on claims that did not have the modifier attached.  It would serve the physician well to investigate if this is being done.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

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