Modifier 25 was introduced in Current Procedural Terminology (CPT®) 1992 and has been the subject of hundreds of articles. To this day, it remains a source of questions and confusion often leading to misuse or lost opportunity for payment. Modifier 25 indicates that a significant, separately identifiable evaluation and management (E/M) service was provided by the same physician or other qualified health care professional on the same day of a procedure or other service. Doesn’t sound that complex—but wait! When is an E/M service significant or insignificant? What does “separately identifiable” mean? Does appending modifier 25 allow reporting of an E/M service regardless of what other procedure or service is provided on the same date?

CPT and the National Correct Coding Initiative (NCCI) manual and code edits for the Medicaid program provide authoritative guidance for reporting modifier 25 (use of Medicaid NCCI edits may vary by payer)...

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