Modifier 25 Reminders

The Current Procedural Terminology (CPT^®) codebook defines Modifier 25 as a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”

When you submit a Blue Cross and Blue Shield of Texas (BCBSTX) Provider Review form requesting review of a previously submitted claim that contained Modifier 25, we will perform a retroactive audit to determine if the services rendered warrant use of this modifier. If we receive a request to add Modifier 25 to a previously submitted claim, medical records are required to complete our review. If appropriate documentation is not included, the Provider Review form will be returned to you along with a request to include medical information explaining the reason for adding the modifier to a claim that was originally sent without one.

Remember these tips when using Modifier 25:

• Documentation must support significant and separately identifiable preoperative and/or postoperative work, above and beyond the usual care associated with the performed procedure.
• Documentation must support that the patient’s symptom, problem or condition required a separately identifiable E/M service.
• The reported E/M service must meet the key components (history, examination and complexity of medical decision making) of the selected E/M service.
• The E/M service must be distinct from the service performed.
• Modifier 25 should only be appended to E/M services and not procedures.
• Modifier 25 is not used to report an E/M that resulted in the decision to perform surgery. Refer to Modifier 57 guidelines for an E/M service which results in a decision for surgery.
• Procedures include preoperative evaluation services necessary prior to performing a procedure or other service. This may include, but is not limited to assessing the site/condition, explaining the procedure, and obtaining informed consent.

Please refer to the CPT codebook for additional details.

As a reminder, BCBSTX actively participates in inquiries and investigations to accurately identify and appropriately address potential fraudulent activities through our Special Investigations Department (SID). The SID is committed to reducing health care costs and helping to protect the integrity of the BCBSTX independently contracted provider network. To learn more about SID, we welcome you to view the SID Fraud Awareness Tutorial on the BCBSTX provider website in the Education and Reference/Related Resources section.

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