- Lab or X-ray services are the only other services provided in addition to the E/M.
- The sole reason of the visit was for the procedure; or
- The E/M service is not above and beyond the primary purpose of the patient encounter.
- Documentation does not support the definition of the modifier.
- Using modifier 25 instead of modifier 57 to report an E/M service that resulted in the decision to perform major surgery.
The patient sees the physician for knee pain. After examining the patient, meeting the criteria for the E/M and making the determination at the time of the visit that the patient needs a joint injection, the physician may use the 25 modifier on the office visit and be paid for the injection also
The physician tells the same patient in in the previous example to come back to his office in two weeks for another injection for the same complaint. He may not bill an office visit with the 25 modifier along with the joint injection. He may only bill the joint injection because this was planned prior to the visit and the criteria for an E/M service would not have been met.
An office visit and suturing a scalp wound could be properly billed together with the use of a 25 modifier if a full neurological