United States: Use Of Modifier 25 - 2017 Medicare Physician Fee Schedule Proposed Rule

The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have reviewed the use of Modifier 25 to unbundle payments for evaluation and management (E/M) services when a procedure is performed. In the 2017 Medicare Physician Fee Schedule Proposed Rule1, CMS has identified 83 target codes for review. Modifier 25 should only be used when services are provided beyond those considered to be part of the procedure performed. The over use of Modifier 25 was noted by the OIG in 20052. In the 2005 report the OIG found that 35% of the claims using Modifier 25 did not meet the billing guidelines, resulting in improper payments. The specific listing of the 83 target codes in the 2017 Proposed Rule could mean increased auditing of the use of Modifier 25. The codes targeted are attached in Table 7 from the proposed rule.

Click here for a full listing of the codes from TABLE 7 from the proposed rule.

Palmetto GBA has published a National Correct Coding Initiative (NCCI) Tool – CPT Modifier 25.3 A summary of the guidelines for proper use of Modifier 25 are as follows:

  • The E/M services must be more than the usual work associated with the procedure.
  • The documentation must support the used of the modifier. In other words, there must be a significant, separately identifiable E/M service that meets the criteria for the code assigned.
  • The modifier should not be used with new patient codes – they are not required, unless the service is chemotherapy, which is not considered surgical.
  • The diagnosis code for the E/M service does not have to be different than the surgical code, even if Modifier 25 is used.
  • NCCI edits must be reviewed for possible bundling.

    • If the code pairs are identified with 0, then the E/M service may not be billed.
    • If the code pairs are identified with 1, then Modifier 25 can be used if there is a separate visit, site, incision/excision, lesion, or injury and the documentation supports the E/M service as above the work necessary for the procedure.

The following are three examples of the correct use of CPT Modifier from the NCCI Tool.

Example 1: Beneficiary medical history: date of service January 3, 2011, CPT code 20610, HCPCS modifier LT (knee joint injection, 0 global days)

  • On January 3, 2011, an E/M service is submitted with CPT code 99214. The patient was scheduled to receive an injection into the left knee. Due to the failure to control pain and inflammation in the left osteoarthritic knee with prior medical treatments (oral meds and joint injections), further evaluation was performed by the physician and TKR (total knee replacement) of the left knee is planned.
  • Outcome: Submit CPT modifier 25 with the visit for the evaluation and planned major surgery to treat the patient's arthritis

Example 2: Beneficiary medical history: date of service February 15, 2011, CPT code 20553 (trigger point injections, 0 global days)

  • On February 15, 2011, an E/M service is submitted with CPT code 99213. The patient was evaluated for treatment of neck pain and elevated blood pressure. The trigger point injections were administered for neck pain. New meds were prescribed to control the patient's elevated blood pressure.
  • Outcome: Submit CPT modifier 25 with the visit for the evaluation and treatment of the patient's elevated blood pressure

Example of Incorrect use of CPT Modifier 25

  • On January 24, 2011, an E/M service is submitted with CPT code 99213 and CPT modifier 25. During the same patient encounter, the physician also debrides the skin and subcutaneous tissues (CPT code 11042, 0 global days). CPT 99213 was submitted to reflect the physician's time, examination and decision making related to determining the need for skin debridement. The physician's time was not significant and separately identifiable from the usual work associated with the surgery, and no other conditions were addressed during the encounter.
  • Outcome: Do not submit the E/M service. The E/M service is not separately reimbursable from the surgical procedure. Submit only the surgical procedure (CPT code 11042).


Because of the increased focus on the use of Modifier 25, an analysis of provider billing is suggested. If a higher than expected volume is noted by any provider, it would be necessary to conduct a targeted audit to determine if there is sufficient documentation to support the use of Modifier 25.

The increased focus by CMS noted in the 2017 Physician Fee Schedule Proposed Rule should heighten awareness for all providers regarding the correct use of Modifier 25. Education concerning the correct use of Modifier 25 for providers, coders and billing staff is a good first step.


1. https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16097.pdf

2. https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

3. http://www.palmettogba.com/palmetto/webTool.nsf/vTool/mod25

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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