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Appending Modifier 25 to an Evaluation and Management (E/M) service has always been fraught with confusion, and the Office of Inspector General (OIG) has scrutinized it for overuse and abuse.
Defined as a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service. (CPT 2024). To report Modifier 25 appropriately, there must truly be a significant, separately identifiable E/M service substantiated by documentation that satisfies the relevant criteria for the respective E/M service. Remember that the global surgical package for every procedure is valued with some level of evaluation and assessment to perform the procedure. The Evaluation and Management service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required to report the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M. CMS further considers that an E/M service performed on the same day as a procedure is inherent to the procedure. Medicare only pays for an Evaluation and Management service if the work involved is “above and beyond” the preoperative evaluation services. (Source: NCCI Chapter 12 pg. 33.)
Payors are now adding an additional layer of complexity by reducing the Evaluation and Management service by 50% when a separately identifiable E/M service is rendered in addition to the minor procedure performed.
For some payors, like Horizon Blue Cross and Blue Shield, this policy change took effect on February 1, 2023. As of June 25, 2024, several Blues are following suit:
- BCBS of Texas April 19, 2024
- BCBS of California July 14, 2024
- BCBS of North Carolina September 1, 2024
It's crucial to note that other payors are likely to follow suit in altering their reimbursement policies for Evaluation and Management (E/M) services when Modifier 25 is used. Immediate and focused attention is needed to understand and adapt to these changes and to stay informed about potential future changes.
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