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The Do’s and the Don’ts of Modifier 25

Coding
Dr. Karen Sedore
in Coding
By Karen Sedore DC CPCO

In the realm of coding and documentation, it is often thought that “more is better.” However, when it comes to adding the 25 modifier to Evaluation & Management (E/M) services, it is important to understand when it is really needed and when it’s best to leave it off. The Office of the Inspector General (OIG) has identified the use of modifier 25 as an area of potential overuse and misuse.

Chiropractors are a little different from their medical and osteopathic colleagues who bill for E/M services on almost every visit. Chiropractors bill a Chiropractic Manipulative Treatment (CMT) code almost every visit as our primary service. When a CMT is performed and billed, it includes a pre- and post- manipulation patient assessment and, thus, evaluative services are inherent to this core service. According to CPT guidelines, the 25 modifier is used in conjunction with E/M codes for both new and established patients to indicate that the evaluative services were separate and distinct from the chiropractic manipulation and that both were performed on the same visit. Unless a separate and distinct evaluation is also performed, a separate E/M service should not be routinely billed on a visit-to-visit basis by chiropractors. However, there are instances when it is appropriate to bill both the E/M code and the CMT on the same visit. When doing so, it’s critical that both doctors and their staff understand what constitutes separate and distinct evaluation and management, and therefore, when modifier 25 should be used.

When to Add Modifier 25

If the work of both CMT and a distinct E/M service is performed, it’s completely appropriate to bill both. Some specific examples of when it is appropriate to bill for both a CMT and E/M code on the same date of service are:

  • A new patient visit, in which you also adjust on the first visit
  • An established patient presenting with new condition, new injury, aggravation, or exacerbation, and the decision is made to also adjust on that visit
  • A periodic re-evaluation to assess if a treatment change is needed, and the decision is made to provide treatment the same day

Remember, the 25 modifier is added to the E/M code (99201-99205, 99212-99215), not the CMT code (98940-98943) and BOTH must be performed during the same visit. If only an E/M service is billed, the 25 modifier is not required.

What About 99211?

CPT code 99211 is the lowest level of Established Patient E/M visit code. The three key-components of E/M coding are the level of history performed, the level of examination performed, and the level of clinical decision making required. The values of these three components for code 99211 are nil. This indicates that the code doesn’t even require the presence of a physician and is therefore rarely, if ever, used in a chiropractic office. We urge chiropractic practices to review their use of this code, and consider whether it should be in your coding list. We suggest that it should be removed, and 99212 be considered as the lowest established patient E/M code used in the practice.

Sometimes an Exam Isn’t an Exam

It may be clinically indicated to assess a patient’s condition prior to rendering treatment, but not all of these encounters meet the criteria to be considered an E/M service. Some situations where an exam shouldn’t even be billed include:

  • When palpating or observing range of motion to determine if a subluxation is present
  • When a patient’s condition is slightly exacerbated or if the patient presents with new symptoms for which you determine an evaluation is not necessary
  • For a verbal Report of Findings, if done on a separate day as the E/M service

Becoming an E/M Modifier Expert

It’s no secret that E/M services are a necessary part of good patient care and, when billed appropriately, should be paid by third-party payers. Don’t be discouraged if your claims, billed properly with the 25 modifier, return as denials. This is a widespread issue affecting chiropractors across the country and with various insurance carriers, especially some Blue Cross/Blue Shield carriers. The key to success is to appeal these denials by sending supporting documentation that proves a significant, separately identifiable E/M service was in fact performed during the same visit as your CMT. Include a summary of your justification for doing so. To make sure modifier 25 was used correctly, ask yourself the following questions:

Modifier 25 Decision Making Matrix

During your next routine internal audit, be sure to review the use of the 25 modifier with the E/M codes billed in your practice. Verify that your billing software isn’t adding the modifier without your knowledge. If issues arise, whether it is human or computer error, take the necessary steps to correct the improperly billed claims and create a policy in your office to ensure correct modifier usage in the future.


Dr. Karen Sedore has over 10 years of experience working in the chiropractic profession.  She began as a manager specializing in billing and medical necessity as well as taking on chiropractic assistant responsibilities so that she could be more involved with patient care.  In 2016, Dr. Sedore received her doctorate in Chiropractic from National University of Health Sciences. She joined KMC University in 2017 and assists doctors and their staff in her current role as an Account Manager.

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