CPT Modifier 25
CPT Modifier 25 Team Lead
Former DOJ Attorney
CPT Modifier 25 Team Lead
Current Procedural Terminology (CPT) Modifier 25 is a powerful tool for healthcare providers in the United States. When used properly, CPT Modifier 25 allows healthcare providers to bill separately for services provided to a patient in the same encounter.
However, misuse and abuse of CPT Modifier 25 are common, and this has resulted in healthcare providers who use this modifier facing enhanced scrutiny in recent years. Under the False Claims Act (FCA), healthcare providers that use CPT Modifier 25 to fraudulently bill Medicare and other programs can face steep penalties—and they can face ongoing review of their program billings as well.
What Healthcare Providers Need to Know About CPT Modifier 25
As the American Medical Association’s (AMA) Issue Brief on CPT Modifier 25 explains, this modifier may be “appended to an evaluation and management service (E/M) code on a claim to indicate the code is a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service.” As a result, when used properly, CPT Modifier 25 allows healthcare providers to bill separately for, “two E/M services or a procedure plus an E/M service that are distinctly different but required for the patient’s condition to be appropriately reported and, therefore, appropriately paid.”
Healthcare providers frequently use CPT Modifier in connection with the following billing codes (among others):
- CPT Code 99203 (office or outpatient visit for E/M of a new patient)
- CPT Code 99212 (office or outpatient visit with an established patient lasting 10-19 minutes)
- CPT Code 99213 (office or outpatient visit with an established patient lasting 20-29 minutes)
- CPT Code 99214 (office or outpatient visit with an established patient of moderate complexity)
- CPT Code 99215 (office or outpatient visit with an established patient lasting up to 40 minutes)
If an E/M visit with a new or established patient identifies the need for additional E/M services, using CPT Modifier 25 allows healthcare providers to submit an additional billing code—provided that the additional preventive medicine visit is “significant [and] separately identifiable evaluation.” As the AMA’s Issue Brief goes on to explain:
“CPT states that a significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. . . . Further, the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.”
Crucially, the AMA also makes clear that simply asserting eligibility for CPT Modifier 25 on a bill or reimbursement request is not enough. Rather, documentation of the medical necessity and level of medical decision making is required—and, in the event of a billing audit or healthcare billing fraud investigation, this documentation must be readily available to substantiate the submission of multiple E/M codes:
“While CPT does not outline required documentation for modifier 25, its use indicates that documentation is available in the patient’s record to support the reported E/M service as distinct and separately identifiable.”
The use of CPT Modifier 25 is not appropriate when services billed using a standard E/M billing code (i.e., CPT Code 99203 or CPT Code 99214) do not lead to additional services outside of those “usually” billed with the standard code. For example, the AMA explains that when CPT Modifier 25 is used to submit multiple billing codes in connection with a procedure, the appended E/M billing code should reflect services, “performed above and beyond the usual preoperative and postoperative services associated with the procedure performed on the same date of service.” As examples, the AMA identifies the following as preoperative and postoperative services that generally do not warrant the use of CPT Modifier 25:
- Review of the patient’s medical history
- Assessment of the condition that requires treatment (including surgery)
- Formulation and explanation of the patient’s diagnosis
- Review and explanation of the proposed treatment
- Discussion of alternate treatment options
- Obtaining informed consent
- Providing postoperative care instructions and discussing any further treatment or follow-up care
With this in mind—and recognizing that improper use of CPT Modifier 25 has the potential to trigger scrutiny (and penalties) under the FCA—it is imperative that healthcare providers prioritize compliance. In the event of a billing audit or healthcare billing fraud investigation, being able to present not only documentation that substantiates individual uses of CPT Modifier 25 but also documentation that demonstrates a broader good-faith commitment to compliance can be essential for avoiding unnecessary consequences.
Put our highly experienced team on your side
Dr. Nick Oberheiden
Founder
Attorney-at-Law
Lynette S. Byrd
Former DOJ Trial Attorney
Partner
Brian J. Kuester
Former U.S. Attorney
Hon. Kevin McCarthy
55th Speaker, U.S. House of Representatives (ret.)
Government Consultant
Mike Pompeo
Of Counsel
Former U.S. Secretary of State
John W. Sellers
Former Senior DOJ Trial Attorney
Linda Julin McNamara
Federal Appeals Attorney
Nicholas B. Johnson
Former Prosecutor
Roger Bach
Former Special Agent (DOJ)
Chris J. Quick
Former Special Agent (FBI & IRS-CI)
Michael S. Koslow
Former Supervisory Special Agent (DOD-OIG)
Ray Yuen
Former Supervisory Special Agent (FBI)
If you are facing scrutiny related to your practice’s use of CPT Modifier 25, you need to take your situation very seriously. If substantiated, allegations of improperly using this modifier to overbill Medicare and/or other payors can lead to penalties including:
- Recoupments
- Treble damages
- Additional financial liability
- Denial of pending claims
- Pre-payment review of future claims
All of these penalties can have serious financial consequences—and they can be practice-threatening in some cases. In egregious cases of misuse of CPT Modifier 25, healthcare providers can also face exclusion from Medicare and other programs; and, if auditors or investigators find evidence of intentional misuse, this can potentially lead to criminal charges for federal healthcare fraud.
At Oberheiden P.C., we defend physicians, surgeons, hospitals, clinics, and all other types of healthcare providers facing scrutiny under the FCA. This includes scrutiny related to our clients’ use of CPT Modifier 25. As former federal healthcare fraud prosecutors, many of our attorneys have extensive experience on both sides of FCA inquiries, and our team also includes former federal investigative agents who have in-depth knowledge of the government’s processes, procedures, and priorities when seeking evidence of billing fraud.
FAQs: CPT Modifier 25 and the False Claims Act (FCA)
When Can Healthcare Providers Use CPT Modifier 25?
Due to the substantial risks involved with improperly using CPT Modifier 25, it is imperative that healthcare providers have a clear understanding of when using this modifier is appropriate. As the AMA explains, there are two scenarios in which CPT Modifier 25 is typically used: (i) “[a] preventative medicine E/M service provided with a problem-oriented office or other outpatient E/M service;” and, (ii) “[a] minor surgical procedure provided with a problem-oriented office or other outpatient E/M service.”
While these are not the only scenarios in which CPT Modifier 25 may be used, when using the modifier in other scenarios, it will be especially important for healthcare providers to confirm compliance. In all cases, however, proper documentation is critical, and healthcare providers must be confident that they will be able to justify their use of CPT Modifier 25 if necessary.
When is It Improper to Use CPT Modifier 25 for Additional Healthcare Services?
While CPT Modifier 25 is applicable in a wide range of scenarios, it is also frequently misused by healthcare providers across all disciplines. This modifier is intended for use specifically in circumstances involving the provision of an evaluation and management (E/M) service that results in the need for an additional E/M service. If an additional service does not fall under the E/M umbrella, or if the “additional” service is included under the original E/M service for billing purposes, then the use of CPT Modifier 25 is improper.
When Do Healthcare Providers Need to Use CPT Modifier 57 Instead of CPT Modifier 25?
While CPT Modifier 25 is used to bill for most necessary additional E/M services identified during a patient visit or procedure, CPT Modifier 57 is used to bill for E/M services that uncover the need for surgery. As the AMA explains, “Modifier 25 should not be used to report an E/M service that results in a decision to perform surgery (modifier 57 should be reported in this instance).”
When Do Healthcare Providers Need to Use CPT Modifier 59 Instead of CPT Modifier 25?
CPT Modifier 59 is used to bill for a “distinct procedural service” provided in connection with an E/M service billed using a common billing code such as 99203, 99212, 99213, 99214, or 99215. CPT Modifier 25 is used to bill for separate E/M services that are allowed to have separate payment from those provided and billed under different procedure codes or diagnosis codes.
What Are the Consequences of Improperly Using CPT Modifier 25?
Improperly using CPT Modifier 25 can have serious consequences for healthcare providers. Not only can this result in denial of the relevant reimbursement claim, but it can also lead to scrutiny under the False Claims Act. Facing scrutiny under the False Claims Act is a high-risk scenario that requires experienced legal representation—as a finding of healthcare billing fraud can lead to financial and other penalties.
Schedule a Call with a Healthcare Defense Lawyer at Oberheiden P.C.
If you are facing scrutiny related to your practice’s use of CPT Modifier 25, we encourage you to contact us promptly for more information. To schedule a call with a senior healthcare defense lawyer at Oberheiden P.C., please call 888-680-1745 or contact us confidentially online today.
