“Don’t follow the crowd, let the crowd follow you” — Margret Thatcher This morning I noticed some daffodils defiantly blooming in the woods. While their defiance may have really been courtesy of the neighborhood squirrels, it still made me smile…
Modifier 25: Significant & Separately Identifiable
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Modifier 25: Significant & Separately Identifiable
Practice Corner FAQ’s
We receive regular questions about when to use modifiers. The video clip is an excerpt from our Annual Meeting 2024 presentation, “If It’s Not Documented, It Didn’t Happen.” In this clip, Teresa Thompson, BS, CPC, CMSCS, CCC and Robert Puchalski, MD discuss the nuances and uses of modifier -25.
The AMA’s CPT definition for Modifier -25 is:
Modifier 25: Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
Source: American Medical Association. Reporting CPT Modifier -25. CPT*Assistant (Online). 2023;33(11):1-12. Accessed March 6, 2025.
This link [https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf] offers essential insights for the appropriate use of modifier -25, including:
• Modifier -25 should only be used with E/M codes.
• Modifier -25 is not restricted to a specific level of E/M service.
• The E/M service provided must meet the criteria applicable to that service (i.e., medically appropriate history and/or examination, and medical decision making or total time on the date of the encounter within code parameters).
• CPT coding guidelines do not require different diagnoses for the E/M service and the additional procedure or service performed when modifier -25 is used.
• 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).
• Modifier -25 should only be used when the E/M service is significantly and separately identifiable from the procedure or other service performed on the same patient, on the same day.
• The significantly and separately identifiable E/M service(s) provided must be properly documented in the medical record.
For AAOA, this question is most often associated with whether or not an E/M code may be billed in conjunction with allergy shots. As highlighted in the video, only if the E/M is provided for a condition or problem other than allergy and is separately identifiable. If this is true, then an E/M with modifier -25 may apply. We encourage clear and appropriate documentation in the patient’s medical record.
The full “If It’s Not Documented, It Didn’t Happen” session and other practice resources are available in the “Work Smarter, Not Harder” virtual education stack.
The American Academy of Otolaryngic Allergy (AAOA) Practice Resources are intended as a guide to help AAOA members integrate allergy into their otolaryngology practice and to continually improve on this integration as new information, regulations, and resources become available.
While these tools are meant as resources, we highly recommend seeking input from your practice counsel and local/state medical associations and regulatory authorities, as rules vary between states. Each practice is responsible for confirming coverage, coding, and payment parameters for those payers and regulators affecting their practice. Our intention is to offer insights by sharing what others within AAOA do. These are not meant as recommendations.
