Modifier-25

Modifier-25: Significant, Separately Identifiable E/M Service

Modifier-25 can be used to report accurately when a significant, separately identifiable E/M service is performed on the same day of service as a procedure (OMT).

The take-away: It’s important to understand what Modifier-25 means to ensure your claims aren’t denied.

OMT was assigned a 000-day global designation by CMS and, therefore, falls into the category of an endoscopic or minor surgical procedure. As a result of this global period, if a practitioner reports Evaluation and Management (E/M) services and OMT services on the same date of service, then the E/M services will be denied or paid with the payment for OMT. However, both CMS and the AMA CPT provide guidance when exceptions to the global period rules apply.

CMS NCCI edits and the CPT guidelines for Osteopathic Manipulative Treatment (OMT) have stipulated that E/M services and OMT can be reported on the same date of service with the use of Modifier-25.

There are two key definitions for Modifier-25:

Modifier-25 is appropriate to use when the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual pre-service and post-service work associated with the procedure. The E/M service may be for the same symptoms or condition that warranted the OMT. Therefore, different diagnoses do not need to be reported when an OMT and an E/M service are reported on the same date of service.

CPT OMT Modifier-25 Guidelines:

Modifier-25 is used when the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual pre-service and post-service work associated with the procedure. The E/M service may be related to the same symptoms or condition for which the OMT was provided. Therefore, different diagnoses are not required when reporting both the OMT and E/M service on the same date.

CPT Appendix A Modifier-25 Guidelines:

Modifier-25 is used when the patient’s condition requires a significant, separately identifiable E/M service, above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed.