Become perfect in Using Modifier 25 with Examples

CPT modifiers are very tricky to use in medical coding. If you ask any coder which are tough codes to use, they will immediately reply MODIFIERS. Yes, even the experienced medical coders fail to apply and use modifiers correctly.

We have learnt about many modifiers like the use of 26 and TC component, 32 & 33 modifier, 62 versus 80 modifier, 25 & 27 modifier etc. but still to understand them with the help of examples will surely help you know them more clearly.

New medical coders who are new to coding and learning about reading and coding a medical report will surely get benefited with this article.

Today will learn how to use modifier 25 with some coding scenarios.

Correct/Incorrect use of Modifier 25 with the appropriate level of E/M service.

Medicare allows payment for an E/M service with 25 modifier which occur on the same day as a procedure. Documentation should support the use of 25 modifier.

Modifier 25 used by a physician other than the physician performing the procedure is totally incorrect use of 25 modifier.

Example 1

A established patient is scheduled for follow up E/M and the physician reports procedure or E/M code 99213 as per the documentation. But, the patient met with an wound injury with a piece of glass into his skin. The physician performs removal of foreign body exam and report cpt code 20520, which has 10 days global period.

Now this scenario will be reported with CPT code 99213-25, 20520

20520 – Removal of foreign body in muscle or tendon sheath; simple

Example 2

Suppose a established patient has a severe laceration to the scalp and physician reports E/M service code 99214 for his visit as per documentation which supports detail history and exam. Now, the physician performs the intermediate repair of the scalp, which is reported with cpt code 12032.

Now, this scenario will be reported with CPT code 99214-25, 12032

12032 – Repair, intermediate, wounds of scalp, axilla, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm

Example 3

Now, suppose a patient visits a physician for removal of lesion from his right leg. The physician after examination performs a procedure to remove the lesion and a simple closure exam was performed. Since the exam was only for removal of lesion, hence this scenario will be reported with only CPT code 11400.

11400 -Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less

Example 4

A established patient is seen for follow up for his hypertension and diabetes mellitus. He also complains of shoulder pain. The physician performs a Problem focused history and exam. The physician also tested his Blood pressure and his hypertension. The physician also performs a shoulder joint injection exam or arthrocentesis for his shoulder pain.

Now, this scenario will be reported with CPT code 99212, 20610-RT