What The Procedure Already Includes
Minor procedures, such as biopsies, destructions and injections, carry a 0 or 10 day global period that includes the decision to perform the procedure and the routine assessment that goes with it. Examining a lesion and deciding to biopsy it does not support a separate visit.
When Modifier 25 Fits
- The patient is evaluated for other problems at the same visit, such as a full skin exam with management of other conditions
- A new problem is diagnosed and managed beyond the procedure
- A chronic condition is managed with medication changes or counseling unrelated to the procedure
Documentation
The note should make the separate service easy to see: the additional problems addressed, the assessment and plan for each, and the procedure note on its own. Different diagnoses help but are not required, and the same diagnosis does not by itself rule out a separate visit.
The 2027 Medicare Change
In the CY 2027 Physician Fee Schedule final rule, CMS finalized a 20 percent payment reduction for the lower-paid service when an office visit and a minor procedure are billed on the same day. Modifier 25 is still required to report both, but the visit or procedure will pay less starting in 2027. Practices should model the effect on their mix of visits and procedures.
Frequently Asked Questions
- Does a new patient visit automatically qualify for modifier 25?
- No. The test is whether the work goes beyond the procedure's included evaluation, not whether the patient is new.
- Is modifier 25 used with major surgery?
- No. For an E/M visit that results in the decision for a 90-day global procedure, modifier 57 is used instead.
Billing Support For This Specialty
Physicians Professional Billing Services, Inc. has billed wound care, surgical and procedural specialties since 1998, across every Medicare Part B MAC jurisdiction.
Primary Sources
This page is general information about billing and coverage rules and is not legal, coding or reimbursement advice for a specific claim. Coverage policies change; confirm current requirements with CMS and the applicable Medicare Administrative Contractor.