The Proper Use of the 25 Modifier
E/M Services
1. E/M is NOT a synonym for an office visit.
2. It is a 2-part process:
- “E” stands for EVALUATION. Using a Medically Appropriate History and/or Examination and *Medical Decision Making, you formulate a WORKING DIAGNOSIS. This shows MEDICAL NECESSITY.
- “M” stands for management. Using the working diagnosis, you now have to do something about it. In other words, you have to TREAT THE PROBLEM. Diagnosing a problem is not sufficient.
3. *Total Time can be used in lieu of Medical Decision Making in order to determine the most appropriate level of E/M service as long as the total time is appropriately documented within the medical record for the date of service in question.
-And, if that is not enough,
4. ALL CPT (Procedure) codes have an inherent E/M component.
5. In order to bill an E/M service and a CPT code on the same date of service, whether it is an initial encounter or a subsequent encounter, you must through your documentation demonstrate the thought process that was used to extract the E/M component from the CPT code to make the E/M service significant and separately identifiable.
6. You can NEVER, EVER bill an E/M code in lieu of the appropriate CPT code.
Appropriate Use of the 25 Modifier
- It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual pre and postoperative care associated with the procedure that was performed.
- 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. (Added Note: The language in this sentence implies that your documentation for the use of the -25 modifier contains a separate Medically Appropriate History and/or Examination and Medical Decision Making for that separate E/M service.
- 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 day. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. NOTE: This modifier is not used to report an E/M service that resulted in a decision to perform surgery (ie. Major Procedural Service – 90 day postoperative global period) . See modifier 57. For a Distinct Procedural Service, see modifier 59.
Example of Documentation to Demonstrate a Significant and Separately Identifiable E/M Service (ie. Plantar Fasciitis)
- A medically appropriate history, a medically appropriate examination and medical decision making of low complexity were performed and documented. This supported a significant and separately identifiable E/M service.
- Treatment options/alternatives were discussed with the patient including wearing a firm fitting, supportive sneaker, Rx/OTC orthotics, physical therapy, cortisone injection.
- All questions by the patient were addressed, discussed and answered.
- After a discussion with the patient, it was decided to administer a cortisone injection into the plantar aspect of the right heel at the insertion of the plantar fascia into the calcaneus.
Example of Documentation to Demonstrate a Significant and Separately Identifiable E/M Service (ie. Onychomycosis)
- A medically appropriate history, a medically appropriate examination and medical decision making of low complexity were performed and documented. This supported a significant and separately identifiable E/M service.
- Treatment options/alternatives were discussed with the patient including Rx oral medication, Rx/OTC topical medication, a general treatment plan for onychomycosis: The patient was instructed to keep their feet clean, dry between their toes, change their socks and shoes daily and apply a topical antifungal medication to the affected nails on a regular basis.
- All questions by the patient were addressed, discussed and answered.
- After a discussion with the patient, it was decided to prescribe the patient a topical antifungal medication or provide the patient with an OTC topical antifungal medication.
An INITIAL E/M service CAN be billed when performed on the SAME date of service as a minor surgical procedure.
- The diagnosis code for the INITIAL E/M service and the diagnosis code for the minor surgical procedure CAN be the SAME.
AN ESTABLISHED patient E/M code CAN be billed when performed on the same date of service as a minor surgical procedure code.
- The diagnosis code for the established E/M service MUST BE DIFFERENT from the diagnosis code for the minor surgical procedure.
- There can be absolutely, positively NO CORRELATION between the E/M service and the minor surgical procedure.
If an established patient is seen for a NEW problem that has never been evaluated for previously (ie. never mentioned, never examined, never treated) and a minor surgical procedure is performed on the SAME date of service, then not only can BOTH the established patient E/M service code AND the minor surgical procedure code be billed for, but the diagnosis code for the E/M service and the diagnosis code for the minor surgical procedure can be the SAME.
- Of course, the entire scenario needs to be completely documented in the medical record.
This is my opinion.
Michael G. Warshaw, DPM, CPC
THE 2025 PODIATRY CODING MANUAL IS STILL AVAILABLE in either Book or Flash-drive formats. It has been completely updated for the calendar year 2025. Many offices across the country consider this to be their “Bible” when it comes to coding, billing, and documentation. The price is still only 125.00 including shipping! To
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Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 32757
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