Crack the modifier -25 code

The American Medical Association (AMA) published additional guidance for modifier -25 (significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service) in its recent publication of CPT^® Assistant, March 2023, Modifier -25 Reporting, p. 1.

While the modifier itself was not revised for the CPT 2023 code set, the AMA felt that there was still some confusion regarding modifier -25 and its use.

This article reviews the AMA’s guidance on correct reporting of modifier -25, and outlines when and how to report it.

Purpose of modifiers

Modifiers provide additional information that enable health care professionals to communicate to payers that a service and/or procedure performed was somehow impacted by a specific incident, but does not necessarily change the CPT code reported. There are numerous modifiers and multiple reasons why they are utilized.

For example, modifiers such as -LT (left side)/-RT (right side) are anatomical modifiers that specify laterality. Other modifiers, such as -52 (reduced services) and -76 (repeat procedure by same physician), are surgery specific.

Modifier -25 is used when distinct services are performed on the same day – specifically, services that may be reported separately and require additional work. Recognizing the additional work and when it is considered “significant” is key.

A list of modifiers and their definitions can be found in Appendix A of the 2023 CPT Manual.

For more on the appropriate use of modifier -25, read the full article in JustCoding.

Courtney Crozier is a clinical development analyst at Solventum.