Modifier 25 with Evaluation and Management Services Reported with Procedures

Date Issued: 7/19/2018

Modifier 25 is used to describe a significant, separately identifiable evaluation and management (E/M) service that was performed at the same time as a procedure.

Beginning October 30, 2018, our current coding policy will apply to GHI plans regarding E/M services billed with modifier 25 within 28 days of a previous face-to-face service. The E/M service will be denied when both of the following apply:

• The E/M service (92002-92004, 92012-92014, 99201-99380, 99441-99499) is billed with modifier 25 on the same day as a procedure with a 0-day, 10-day, or 90-day postoperative period.

• The patient has had a face-to-face service with the same provider for the same condition as the E/M service, and the 0-day, 10-day or 90-day procedure within the previous 28 days.

Face-to-face service codes included in this medical policy: 10021-36410, 36420-44680, 44800-69990, 90935-90993, 92002-92371, 92502-92504, 92511, 95831-95852, 96365-96379, 96405-96406, 96440, 96450, 96542-96999, 97597-97755, 97802-98943, 99100-99170, 99201-99285, 99291-99337, 99341-99357