April 21, 2024

Do we have to put modifier -25 on an evaluation and management (E/M) level?

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Originally, CMS stated in PM A-00-40 that all ED visits required the use of modifier –25 when billing a procedure performed in the ED. CMS further clarified in PM A-01-80 that it is not necessary to use modifier -25 when the procedure does not have a status indicator of S or T. CMS also said if a facility were to place modifier -25 on a procedure that didn’t have status code S or T, the outpatient code editor (OCE) would still process the claim without delay.


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Do we have to put modifier -25 on an evaluation and management (E/M) level if we bill for CPT 94760, “pulse oximetry,” as an additional procedure in the ED? Our bills are kicking out from our FI when we don’t use modifier -25 with CPT 94760, even though 94760 is packaged.

Originally, CMS stated in PM A-00-40 that all ED visits required the use of modifier –25 when billing a procedure performed in the ED. CMS further clarified in PM A-01-80 that it is not necessary to use modifier -25 when the procedure does not have a status indicator of S or T. CMS also said if a facility were to place modifier -25 on a procedure that didn’t have status code S or T, the outpatient code editor (OCE) would still process the claim without delay.

We suggest you ask your software company why it requires modifier -25 for a packaged service. It is likely that your FI has not updated its software to conform to the newest policies set forth in previously mentioned PMs. We suggest you bypass the edit until the software is properly updated. If you receive this edit from your FI, ask customer service why the FI is editing for items that CMS stated were appropriate based upon published PMs.

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Do we have to put modifier -25 on an evaluation and management (E/M) level?
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Do we have to put modifier -25 on an evaluation and management (E/M) level?
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Originally, CMS stated in PM A-00-40 that all ED visits required the use of modifier –25 when billing a procedure performed in the ED. CMS further clarified in PM A-01-80 that it is not necessary to use modifier -25 when the procedure does not have a status indicator of S or T. CMS also said if a facility were to place modifier -25 on a procedure that didn’t have status code S or T, the outpatient code editor (OCE) would still process the claim without delay.
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