Glossary · Coding
Glossary · CodingModifier 25
A CPT modifier appended to an E/M code on the same day as a procedure to indicate that the E/M service was significant, separately identifiable, and above the work normally included in the procedure.
Definition
Modifier 25.
A CPT modifier appended to an E/M code on the same day as a procedure to indicate that the E/M service was significant, separately identifiable, and above the work normally included in the procedure.
Sources
Primary references for this entry.
- AMA CPT Modifiers reference.
- AAPC Modifier 25 coding guide.
Related terms
Other terms in Coding.
- Coding
APC (Ambulatory Payment Classification)
The CMS payment grouping system used for hospital outpatient services under the Outpatient Prospective Payment System (OPPS). APCs bundle services into payment categories with relative weights.
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Bundling
Payer policy that combines multiple billed services into a single payment when one is considered an integral component of another. Often enforced through NCCI edits.
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CPT (Current Procedural Terminology)
The American Medical Association's standardized code set for medical, surgical, and diagnostic procedures. Five-digit numeric codes (with two-digit modifiers) used for professional billing on the CMS-1500 form.
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Downcoding
A payer adjustment that reimburses a billed service at a lower complexity level than coded, typically when documentation is judged insufficient to support the higher level.
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DRG (Diagnosis-Related Group)
The CMS payment grouping system for inpatient hospital services under the Inpatient Prospective Payment System (IPPS). Each DRG carries a relative weight that determines the lump-sum payment.
Open entry - Coding
E/M Coding (Evaluation and Management)
The CPT code family (99202-99499) for office visits, hospital visits, and consultations. Levels (e.g., 99213 vs 99214) are determined by complexity of medical decision-making or total time.
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Frequently asked
About Modifier 25.
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