Forum - Questions & Answers

Jan 16th, 2018 - daystarjj 4 

Modifier 25 with New patient visit codes and procedure on same day

I know this subject has been beaten to death, BUT I have spent hours researching this subject and find there are two basic answers - yes, use the modifier and no, do not. Both with good reasoning.

With Anthem's new policy of reducing the visit code reimbursement when modifier 25 is used as well as other carriers sending out scary letters to the docs warning them they are over using. What is the correct way to use modifier 25 in regards to a new patient being seen and a procedure needed on the same day?

Feb 7th, 2018 - ChrisW   256  1 

re: Modifier 25 with New patient visit codes and procedure on same day

There is actually a webinar on this subject on Find-A-Code if anyone is interested: Thursday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 PM EST
Register here:

This modifier is used to communicate that the E/M service was done and not related to the other procedure on the same day. The key is to understand when the extra work is significant and can be identified as separately identifiable services if this is the case it should be billed in addition to the procedure. Documentation must be clearly separate and distinct to be eligible for reporting the 25 Modifier.

Reminder: The 25 Modifier is never applied to the procedure only to the E/M code.

Palmetto GBA states “This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99281, 99285, 99321-99323, and 99341-99345. These codes are 'new patient' codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed”.

• CMS Pub. 100-04, chapter 12, section 40.2-40.5
• CMS Pub. 100-04, chapter 23, section 30.2

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