What is 25 modifier and how to use it for insurance Payment

Terms and conditions to bill 25 modifier

What is a 25 modifier in medical billing?

In general medical billing, you might wonder why the 25 modifiers are often used. if you have seen and come across such a question then you are in the right place.

E/M code in other words (Evaluation and management code) these types of code need 25 modifiers often. The reason for adding a 25 modifier is to show that the procedure is significantly identifiable and should be paid separately.


Flow charts to explain 25 modifier’s usage and purpose

25 modifier uses in medical billing

Example scenario on 25 modifier usage to E/m code

Let us assume that cpt 99202 and 99201 are billed on the same claim. Claim got denied as 99202 included in 99201. But as per the medical records, 99202 is a significant procedure service billed separately on the same day and Needs to be paid separately by the insurance.

In the above case insurance company doesn’t know that 99202 is a separate significant code unless you add 25 modifiers to it. once adding 25 modifier insurance company finds it and check the medical records and approve it for payment.

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