Modifier 25

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Question:  

Do we have to append modifier 25 to the E&M code if only an audiogram were also performed at that same visit? Or does modifier 25 not apply since the audiogram is a diagnostic test? What about when we do an in-office CT on the same day as an office visit – should we append modifier 25 modifier to the E&M code or is it not required because the CT is a diagnostic test?

Answer:

Good questions! The CPT descriptor for modifier 25 is: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. CPT states: “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 preoperative and postoperative care associated with the procedure that was performed.” Recall, however, that there is no pre- or postoperative care associated with diagnostic testing such as audiograms or CT scans.

As you know, since 2008 Medicare has required audiologists to bill directly using the audiologist’s NPI as the billing provider. Therefore, it is not likely that you will have an E&M code and an audiogram on the same claim form to Medicare. So your question about appending modifier 25 to the E&M code is not applicable when the payor is Medicare.

Therefore, modifier 25 on the E&M code is not necessary when also reporting a diagnostic testing code such as an audiogram or CT scan. However, you might find that some payors require the use of modifier 25 but it is not a CPT coding requirement.