Q&A: Determine when to append modifier -25 for visits before surgical procedures

Q: If a patient comes into an outpatient facility for a surgical procedure and the physician evaluates the patient before performing the procedure, can you append modifier -25 to the E/M service?

A: It depends on the scenario. If a patient comes in for surgery, it is a normal part of the procedure for the physician to evaluate the patient and make sure that he or she is OK to have the procedure performed that day. If that is the case, then you should not append modifier -25 to identify a significant, separately identifiable E/M service, nor should an E/M service (CPT codes 99201-99215 or HCPCS code G0463) even be assessed since the evaluation would be considered a routine protocol.

However, if in the process of evaluating the patient, the physician discovers an unrelated issue, or the patient has an exacerbation of a problem and additional work is performed outside the normal periprocedural work, then an E/M service may be appropriate.

For instance, suppose a patient comes in for the surgery and is under a lot of stress. He or she is hyperventilating and experiencing chest pain. These symptoms are unrelated to the surgery for which he or she came in and the physician must evaluate the patient to decide whether he or she can continue with the scheduled surgery. In this case, it would likely be appropriate to bill separately for an E/M service, appending modifier -25 as necessary.

Editor’s Note: Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, CPAR, CPC, COC, and Sarah L. Goodman MBA, CHCAF, COC, CCP, FCS, answered this question during the HCPro webinar, “2018 Modifier Update: Guidance and Regulations for Hospitals.”

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