Introduction

Modifier 25 is one of the most frequently used—and most frequently audited—modifiers in medical billing. It is used when a provider performs a significant and separately identifiable Evaluation & Management (E/M) service on the same day as another procedure or service.

Many minor procedures include a brief evaluation as part of the procedure itself. Modifier 25 should not be used to bill that routine evaluation. Instead, it is appropriate only when the provider performs additional medically necessary work that goes above and beyond the evaluation normally included in the procedure. CMS recognizes Modifier 25 as an allowable NCCI-associated modifier when used correctly.

Modifier Number

Modifier Name

Significant, Separately Identifiable Evaluation & Management (E/M) Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of a Procedure or Other Service

Note: The official CPT® descriptor is copyrighted by the American Medical Association (AMA). The wording above identifies the modifier for educational purposes.

Plain English Explanation

Modifier 25 tells the insurance company:

“The provider performed two separate services during the same visit.”

Those services are:

A medically necessary E/M visit, and
A procedure or other billable service.

The office visit must involve additional history, examination, and medical decision making that is not already includedin the procedure.

Purpose of Modifier 25

Modifier 25 is used to indicate that:

An E/M service was performed.
The E/M service was medically necessary.
The E/M service was significant and separate from the procedure.
The E/M service deserves separate reimbursement.

Without Modifier 25, many payers bundle the E/M service into the procedure payment.

When to Use Modifier 25

Use Modifier 25 when all of the following conditions are met:

✔ The patient receives an E/M service.

✔ A procedure is performed on the same date.

✔ The E/M service is above and beyond the evaluation normally required for the procedure.

✔ Documentation supports separate medical decision making.

✔ Both services are medically necessary.

Common Situations Where Modifier 25 Is Appropriate

Example 1 – Knee Injection

A patient presents with worsening knee pain.

The provider:

Obtains a detailed history.
Performs a comprehensive examination.
Reviews imaging.
Diagnoses osteoarthritis.
Discusses treatment options.
Administers a steroid injection.

Coding Example

99213-25
20610

The office visit is separately billable because it includes significant evaluation and decision making before the injection.

Example 2 – Skin Lesion Removal

A patient presents with a suspicious skin lesion.

The provider:

Evaluates the lesion.
Discusses malignancy concerns.
Reviews treatment options.
Removes the lesion during the same visit.

If the evaluation extends beyond the routine assessment included in the lesion removal, the E/M service may qualify for Modifier 25.

Example 3 – Annual Wellness Visit Plus Acute Illness

A Medicare patient comes for an Annual Wellness Visit but also reports fever, productive cough, and shortness of breath.

The provider performs:

Annual Wellness Visit.
Separate evaluation of the respiratory illness.
Medical decision making.
Prescribes antibiotics and orders a chest X-ray.

The problem-oriented E/M service may be reported with Modifier 25 when documentation supports it. Medicare has specific guidance on Modifier 25 in combination with certain preventive services.

When NOT to Use Modifier 25

Do not use Modifier 25:

❌ For every office visit.

❌ Simply because two CPT codes appear on the same claim.

❌ When the E/M service is limited to the evaluation already required for the procedure.

❌ To increase reimbursement without supporting documentation.

❌ On procedure codes—Modifier 25 is appended only to the E/M code.

Medicare Rules

According to CMS:

Modifier 25 is appended only to E/M codes.
The E/M service must be significant and separately identifiable.
Documentation must support the additional work.
The modifier should not be used to bypass NCCI edits without clinical justification.

Commercial Insurance Rules

Commercial payers generally follow the same principles but may have additional requirements.

Many commercial insurers:

Perform pre-payment review.
Request medical records.
Conduct audits for frequent Modifier 25 usage.
Apply payer-specific edits.

Always review payer-specific billing policies before submitting claims.

Documentation Requirements

Documentation should clearly demonstrate:

Chief complaint.
History of present illness.
Examination findings.
Medical decision making.
Assessment and plan.
Why the E/M service was separate from the procedure.
Medical necessity for both services.

Avoid documentation that simply states:

“Office visit plus procedure.”

Instead, explain the additional evaluation performed.

Real Billing Examples

Example 1

Patient presents with severe shoulder pain.

Provider:

Reviews history.
Performs examination.
Diagnoses bursitis.
Discusses treatment options.
Administers corticosteroid injection.

Coding

99214-25
20610

Example 2

Patient presents for wart removal only.

Provider performs a brief examination required to remove the wart.

Coding

17110

Do not bill an E/M service with Modifier 25 because no separate evaluation was performed.

Example 3

Patient presents with diabetes follow-up and an infected ingrown toenail.

Provider:

Evaluates diabetes.
Adjusts diabetic medication.
Performs nail avulsion.

Coding

99214-25
Appropriate procedure code for nail avulsion.

CMS-1500 Claim Example

Field	Example
CPT Code	99213
Modifier	25
Second CPT	20610
Diagnosis Pointer	Appropriate ICD-10-CM diagnosis(es) supporting each service
Units	1

Common Denial Reasons

Missing Modifier 25.
Modifier attached to the procedure instead of the E/M code.
Documentation does not support a separate E/M service.
Medical necessity not established.
NCCI edit triggered.
Payer considers the E/M service bundled.

How to Correct the Denial

Review the denial reason.
Confirm Modifier 25 is attached to the E/M code.
Review provider documentation.
Verify that the E/M service is separate from the procedure.
Submit records if requested.
Appeal when documentation supports separate reimbursement.

Coding Tips

Modifier 25 applies only to E/M codes.
Do not use it automatically whenever a procedure is performed.
Documentation must justify separate payment.
Understand NCCI edits before billing.
Verify payer-specific guidelines.

Frequently Asked Questions (FAQs)

Q1. Can Modifier 25 be used with every procedure?

No. Only when there is a significant and separately identifiable E/M service.

Q2. Can Modifier 25 be used with preventive visits?

Yes, in certain circumstances when a separate problem-oriented E/M service is provided and documented. Medicare has specific rules for preventive services and Modifier 25.

Q3. Does Modifier 25 guarantee payment?

No. Payment depends on medical necessity, documentation, and payer policy.

Q4. Can Modifier 25 be appended to surgery codes?

No. Modifier 25 is appended only to E/M services.

AR Caller Tips

When working a denied Modifier 25 claim:

Verify the E/M code includes Modifier 25.
Confirm the diagnosis supports separate medical necessity.
Ask whether the payer requires chart notes.
Check if the claim is pending medical review.
Document the payer representative’s name, reference number, and next steps.
Appeal with complete documentation if appropriate.

Interview Questions

Question 1

What is Modifier 25?

Answer: Modifier 25 indicates that the provider performed a significant, separately identifiable E/M service on the same day as another procedure or service.

Question 2

Where is Modifier 25 appended?

Answer: It is appended only to the E/M code, never to the procedure code.

Question 3

What documentation supports Modifier 25?

Answer: Documentation must show a medically necessary E/M service that is above and beyond the routine evaluation included in the procedure.

Question 4

Can Modifier 25 bypass an NCCI edit?

Answer: Only when the clinical circumstances and documentation justify a significant, separately identifiable E/M service. It should never be used solely to override an edit.

Practice Scenario

Scenario

A patient presents with severe ear pain.

The physician:

Performs a detailed history and examination.
Diagnoses acute otitis media.
Prescribes antibiotics.
Removes impacted cerumen during the same visit.

Question

Should Modifier 25 be reported?

Answer

Yes, if the office visit involved significant evaluation and medical decision making beyond the routine assessment required for the cerumen removal, and the documentation clearly supports both services.

Related Modifiers

Modifier 24 – Unrelated E/M service during a postoperative period.
Modifier 27 – Multiple outpatient hospital E/M encounters on the same date.
Modifier 57 – Decision for surgery.

Common Billing Mistakes

Using Modifier 25 on every office visit with a procedure.
Appending Modifier 25 to the procedure code instead of the E/M code.
Billing an E/M service when only routine pre-procedure evaluation occurred.
Failing to document separate medical decision making.
Assuming all commercial payers apply Medicare rules.

Key Takeaways

Modifier 25 is one of the most important E/M modifiers.
It applies only to E/M services.
The E/M service must be significant, medically necessary, and separately identifiable.
Strong documentation is the key to avoiding denials.
Proper use supports accurate reimbursement while reducing compliance risk.

References

CMS National Correct Coding Initiative (NCCI) FAQ Library
CMS Medicaid NCCI Technical Guidance Manual (2026)
American Academy of Family Physicians – Modifier 25 guidance

Conclusion

Modifier 25 is one of the most valuable tools for accurately reporting an Evaluation & Management service provided on the same day as a procedure. Its correct use depends on medical necessity, separate documentation, and sound clinical judgment. When used appropriately, Modifier 25 helps providers receive proper reimbursement for work that extends beyond the routine evaluation included with a procedure. Incorrect use, however, can result in denials, audits, or recoupments. Billers, coders, and AR callers should always review documentation carefully, understand payer-specific policies, and ensure that every claim accurately reflects the services provided.

Educational Disclaimer

This article was prepared with the assistance of artificial intelligence (AI) for educational purposes. It is based on publicly available CMS guidance, Medicare NCCI policies, industry best practices, and other publicly available resources. It is not an official publication of the American Medical Association (AMA), CMS, or any insurance payer. CPT® is a registered trademark of the American Medical Association. Always consult the latest AMA CPT® codebook, CMS manuals, NCCI Policy Manual, Medicare Administrative Contractor (MAC) guidance, and payer-specific billing policies before coding, billing, or submitting claims.