Modifier 25

Modifier 25 indicates that on the day of a minor procedure, the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and postoperative care associated with the procedure or service performed. The use of modifier 25 is critical to providing efficient, high quality, patient-centered dermatology care. However, many carriers are critical of the use of modifier 25. They are performing more audits, looking to institute payment reductions or limitations, and outright denying the E/M services.

All right then: How do I use modifier 25?

In order to identify what constitutes a significant and separately identifiable E/M service, above and beyond the usual pre- and postoperative care associated with a procedure, one must understand the global surgical package. The global surgical package is all the services normally furnished by a surgeon before, during and after a procedure.

Services that are already included in the global surgical package are not separately billable with modifier 25, so you need to know what is included in the procedure’s package. Go to the Academy's Global surgical package page for answers.

If you’re billing for a separate E/M service, that service must stand alone. This means that any components of the service you performed that are already included in the surgical package must be omitted when considering the level of E/M service. If there is distinct (separate) medical decision making information, unrelated to the surgical procedure, left to support a level of E/M service, you may be able to report both the minor procedure and the E/M with modifier 25. If not, report only the minor surgical procedure.

Is Modifier 25 used with all procedures?

You should only use modifier 25 with minor procedures, those with a 0- or 10-day global period.

If the procedure performed is considered a major procedure (90-day global period [e.g. flap, graft]), you need to use modifier 57 instead. Modifier 57 indicates that an E/M service resulted in the initial decision to perform surgery, either the day of or the day before a major surgery. However, remember that the decision to perform surgery is included in the global surgical package of minor procedures.

Remember that private payer policies are sometimes different than Medicare policies. Some payers may prefer modifier 25 whenever an E/M service is billed on the same day as another service, rather than modifier 57. Always check with the payer before billing.

Is the patient new or established?

Some Medicare Administrative Contractors (MACs) may not require the use of modifier 25 for new patient encounters. You would need to bill for the procedure and the new patient visit separately, without any modifier. We recommend checking directly with your MAC for use of modifier 25 with new patient encounters.

Test your knowledge

You can test your knowledge of modifier coding by taking a short Academy quiz, or see other coding quizzes.

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