A patient is seen in the provider's outpatient office for an annual physical exam. A comprehensive history, a detailed exam, and a moderate medical decision making is performed. Several of the patient's existing conditions are discussed and updates are noted. While in the office, the patient receives an immunization that is due as prescribed by CDC standards. Which modifier is appended to the Evaluation and Management code for this date of service?

Question

Quizplus · Accepted Answer

Modifier 25 is used to indicate that on the day of a procedure, a significant, separately identifiable evaluation and management service was performed by the same physician or other qualified health care professional. In this scenario, the patient received both an annual physical exam (which includes evaluation and management) and an immunization, making modifier 25 the appropriate choice to signify the additional, distinct service provided.

A Patient Is Seen in the Provider's Outpatient Office for an Annual