Modifier -25

Question: Please explain how and when we should use modifier -25 when filing insurance for our patients. We are very confused on this issue.

Answer: Ah, the dreaded modifier -25, the bane of many an office. The basic rule is this: You perform a legitimate, separate procedure during a routine office visit. You then indicate to the payer that it is a separate service by adding the -25 modifier to the E&M visit - common sense, and it’s consistent with the American Medical Association’s CPT guidelines.

In reality, however, many, many payers routinely deny claims that include the -25 modifier. Part of the problem is that the rules the AMA sets when publishing CPT guidelines don’t always agree with payers’ rules on modifiers. It’s obviously easy to disagree about what is both significant and separate enough to count.

Fight for the correct interpretation of the rules, instead of just writing off the denials or not coding -25 at all. If it is valid for you to get the reimbursement, if you have done that separate service, you should code and bill for it. And if you get denied, you should appeal it.

Make sure you also consult the correct coding initiative edits.