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PAP223

CPT Modifier 25


Provider Administrative Policy

Section
Claims Submission
Policy Date
August 2008
Status/Date
Revised/June 2012
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

CPT Modifier 25

Use CPT modifier ‘25' to report all significant, separately identifiable evaluation and management (E/M) visits by the same physician on the same day of a minor surgical procedure or other service. A minor procedure is defined as having a 0 or 10 day global time period. A physician may need to indicate that on the day he/she performed a minor procedure or service identified by a CPT code, the patient`s condition required a significant, separately identifiable E/M service beyond the other service provided or beyond the usual preoperative care associated with the procedure performed. In order to bill for the E/M service, all key components (history, examination, medical decision making) must be performed and supported by medical record documentation.

A modifier ‘25' is appropriate for the following situations:

Tetanus Vaccination
If a patient sustains an injury that requires a tetanus shot and an evaluation and management E/M service, attach modifier 25 to the E/M code. The claim should also include the date of injury and an accident diagnosis.

Chiropractic Manipulation and Modalities
When performing a significant, separately identifiable E/M service on the same day as a manipulation or modality providers must modify the E/M service with a modifier 25. Routine pre and post work included with a manipulation is not separately reportable as an E/M. A separate E/M is billable in cases where the patient presents with new or deteriorating clinical complaints that require a full review. At reasonable intervals, providers are required to reevaluate and assess positive findings or formulate a change plan, which typically requires an E/M service as well.

Preventive Medicine Codes
If, while performing a preventive medicine E/M service, you encounter a significant problem that requires additional work to perform the key components of an E/M service, you should also report the appropriate medical E/M code for that service, with the modifier 25 appended.


Policy History

Date Action Reason
June 2012 Revised Transparent language revision
October 2011 Revised Language revision
September 2011 Revised Removed postoperative terminology
January 2011 Revised Global time period defined
August 2008 New Tetanus Vaccination policy made into CPT Modifier 25 policy

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