Modifier 25
Complete guide to understanding Modifier 25, including when a significant, separately identifiable Evaluation and Management service may be reported on the same day as another procedure or service.
Modifier 25 at a Glance
Understand the core concept before reviewing examples, documentation and denial scenarios.
Modifier
Identifies a significant, separately identifiable E/M service reported with another procedure or service on the same date.
Applies To
Evaluation and Management services when the applicable requirements are met.
Same Day
The E/M service and another procedure or service are performed on the same date.
Key Test
The E/M service must be significant and separately identifiable.
Documentation
The medical record must support the separately identifiable E/M service.
What Is Modifier 25?
Learn the definition and the main concept behind this commonly used E/M modifier.
Simple Definition
Modifier 25 is used to report a significant, separately identifiable Evaluation and Management service performed by the same physician or other qualified healthcare professional on the same day as another procedure or service.
The E/M service must be above and beyond the usual pre-service and post-service work associated with the other procedure or service.
The documentation must support the separately identifiable E/M service.
Think of Modifier 25 This Way
E/M service performed
+
Another procedure or service performed on the same date
+
E/M is significant and separately identifiable
↓
Modifier 25 may be appropriate
Core Requirements for Modifier 25
These are the questions a biller, coder or auditor should ask before appending Modifier 25.
- Was an E/M service performed on the same date as another procedure or service?
- Was the E/M service significant?
- Was the E/M service separately identifiable from the other procedure or service?
- Was the E/M service above and beyond the usual pre-service and post-service work associated with the procedure?
- Does the documentation support the E/M service?
- Does the applicable payer policy permit separate reporting under the circumstances?
When Should Modifier 25 Be Used?
The important concept is not simply that two services occurred on the same day.
Separate Problem
The E/M service evaluates a problem or condition that requires work beyond the procedure itself.
Additional Work
The physician performs significant E/M work that is not merely the normal work of the procedure.
Separate Documentation
The documentation supports a separately identifiable E/M service.
When Should Modifier 25 NOT Be Used?
Modifier 25 should not be appended automatically whenever an E/M service and procedure occur on the same date.
- Do not use Modifier 25 solely because an E/M and procedure were billed on the same day.
- Do not use it when the E/M service is only the usual pre-procedure evaluation.
- Do not use it when the E/M service is only the usual post-procedure work.
- Do not use it when the documentation does not support a separately identifiable E/M service.
- Do not use it simply to bypass an NCCI edit. The underlying clinical circumstances must support the modifier.
- Do not assume that every payer applies Modifier 25 in exactly the same way.
Modifier 25 Decision Guide
Use this workflow when reviewing a same-day E/M and procedure claim.
Modifier 25 Billing Examples
Practical examples for medical billers, coders and AR callers.
Scenario
A patient presents with a complaint requiring evaluation and management. During the same encounter, the provider also performs a separately reportable procedure.
Review
If the E/M service is significant and separately identifiable from the procedure, Modifier 25 may be appropriate.
E/M-25Scenario
The patient presents for a procedure. The provider performs only the usual evaluation required to perform that procedure.
Result
The routine evaluation associated with the procedure does not automatically justify a separately reported E/M service with Modifier 25.
Scenario
The patient presents for management of a medical problem. During the same visit, the provider performs a procedure for another clinical need.
Review
If the E/M service is significant, separately identifiable and supported by documentation, Modifier 25 may be appropriate.
Scenario
The provider performs a procedure and documents only the routine assessment necessary to decide whether and how the procedure should be performed.
Result
Routine procedure-related evaluation does not automatically support Modifier 25.
Scenario
In addition to performing a procedure, the provider evaluates another condition and makes a separate treatment decision.
Potential Reporting
E/M-25Modifier 25 may be supported when the additional E/M service is significant, separately identifiable and documented.
Scenario
The provider performs a procedure and documents only the assessment and management that are inherent to that procedure.
Result
Modifier 25 is not automatically supported. The documentation must establish separate, significant E/M work.
Modifier 25 vs Modifier 24
Two commonly confused E/M modifiers with completely different primary purposes.
| Modifier 25 | Modifier 24 |
|---|---|
| Significant, separately identifiable E/M service on the same date as another procedure or service. | Unrelated E/M service during an applicable postoperative period. |
| Same-day E/M and another service are central to the rule. | Postoperative global period is central to the rule. |
| Key concept: separately identifiable | Key concept: unrelated |
| Modifier is appended to the appropriate E/M code. | Modifier is appended to the appropriate E/M code. |
Modifier 25 vs Modifier 57
Another important distinction for surgical claims.
| Modifier 25 | Modifier 57 |
|---|---|
| Significant, separately identifiable E/M service on the same day as another procedure or service. | E/M service resulting in the initial decision to perform major surgery when applicable. |
| Same-day procedure/E/M relationship is the central issue. | Decision for major surgery is the central issue. |
| May apply to various same-day procedure scenarios when requirements are satisfied. | Associated with major surgical procedures under the applicable global surgery rules. |
Modifier 25 Documentation Requirements
Strong documentation is critical when supporting a separately identifiable E/M service.
E/M Documentation
- Chief complaint or reason for visit
- Relevant history
- Examination when applicable
- Assessment
- Medical decision-making
- Treatment or management plan
Separate-Service Support
- Identify the problem evaluated
- Document additional evaluation
- Document medical decision-making
- Support medical necessity
- Show work beyond the procedure itself
- Clearly support the reported E/M service
“If the procedure were removed from the claim, would the medical record still support a separately identifiable E/M service?”
Modifier 25 and NCCI Edits
Modifier 25 should be used only when the clinical circumstances support separate reporting.
The National Correct Coding Initiative contains coding edits designed to prevent improper payment when services should not normally be reported together.
A modifier should never be added simply because an edit appears on a claim.
The medical record and the circumstances of the encounter must support separate reporting.
Common Modifier 25 Denials
Common root causes encountered by AR callers, billers and denial management teams.
E/M Included in Procedure
The payer considers the E/M service part of the normal work associated with the procedure.
Not Separately Identifiable
Documentation does not demonstrate that the E/M service was separately identifiable.
Insufficient Documentation
Medical records do not adequately support the reported E/M service.
Modifier Not Supported
The payer determined that the clinical circumstances did not support Modifier 25.
E/M Not Significant
The documentation supports only the evaluation normally associated with the procedure.
NCCI / Bundling
The claim was processed based on an applicable coding edit or bundling rule.
How to Work a Modifier 25 Denial
Practical workflow for AR callers and denial management teams.
Review the Claim
Verify the E/M code, Modifier 25, procedure code, diagnosis codes, POS and date of service.
Review the Procedure
Determine what procedure or service was performed on the same date.
Review the E/M
Determine whether the E/M service represents significant and separately identifiable work.
Review Documentation
Confirm that the medical record supports the E/M service beyond the normal work of the procedure.
Check NCCI
Review the applicable code-pair edit and modifier indicator when relevant.
Check Payer Policy
Verify the payer’s current requirements and claim processing rules.
Correct or Appeal
Submit a corrected claim when appropriate or prepare an appeal with supporting documentation.
Follow Up
Record the payer reference number, submission date, turnaround time and next follow-up date.
AR Caller Script for Modifier 25 Denial
“I’m calling regarding a claim that was denied because the E/M service was considered included in the procedure.”
“The provider performed a significant and separately identifiable E/M service in addition to the procedure, and the medical record supports the additional evaluation and management work.”
“Could you please confirm the exact denial reason, the applicable edit or policy, and whether the claim can be reconsidered with the supporting medical records?”
Questions to Ask the Payer
- What is the exact denial reason?
- Is the denial related to an NCCI edit?
- What code pair caused the edit?
- What modifier indicator applies?
- Does the payer recognize Modifier 25 for this code combination?
- Does the payer require medical records?
- What documentation is required for reconsideration?
- What is the applicable filing limit?
- What is the appeal or reconsideration process?
Modifier 25 Appeal Strategy
Build the appeal around the additional work performed by the provider.
Identify E/M Service
Clearly identify the denied E/M service and associated Modifier 25.
Identify Procedure
Identify the procedure or service performed on the same date.
Explain Additional Work
Explain why the E/M required work beyond the normal work associated with the procedure.
Provide Documentation
Submit medical records supporting the separately identifiable E/M service.
Address the Edit
If an NCCI or bundling edit applies, explain why separate reporting is supported under the applicable rules.
Request Reprocessing
Clearly request reconsideration and reprocessing when the claim meets applicable requirements.
Common Modifier 25 Billing Mistakes
01. Automatic Modifier 25
Adding Modifier 25 whenever an E/M and procedure occur on the same day.
02. Routine Procedure Work
Treating the normal evaluation associated with a procedure as a separately reportable E/M service.
03. Weak Documentation
Billing the modifier without documentation supporting significant additional E/M work.
04. Ignoring NCCI
Failing to review the applicable code-pair edit and modifier indicator.
05. Confusing 24 and 25
Using Modifier 24 for a same-day separately identifiable E/M situation or Modifier 25 for an unrelated postoperative E/M.
06. Ignoring Payer Rules
Assuming every payer processes Modifier 25 claims identically.
Modifier 25 Practice Scenarios
Test your understanding.
Scenario 1 — Separate Medical Problem
A patient presents with a medical complaint. During the same encounter, the provider also performs a procedure.
Answer:
Modifier 25 may be appropriate if the E/M service is significant, separately identifiable and supported by documentation.
Scenario 2 — Routine Procedure Evaluation
The patient presents for a procedure and the provider performs only the normal evaluation required to perform that procedure.
Answer:
Modifier 25 is not automatically supported because the E/M work is part of the normal procedure-related work.
Scenario 3 — Significant Additional Evaluation
The provider performs a procedure and also evaluates another condition requiring additional history, assessment and management.
Answer:
Modifier 25 may be appropriate when the E/M service is significant and separately identifiable and the documentation supports the service.
Modifier 25 Interview Questions
What is Modifier 25?
Modifier 25 identifies a significant, separately identifiable E/M service performed on the same day as another procedure or service when applicable requirements are met.
What is the key concept of Modifier 25?
The key concept is significant and separately identifiable.
Does same-day automatically mean Modifier 25?
No. The E/M service must meet the applicable requirements and be significant and separately identifiable from the other service.
Can Modifier 25 be used to bypass an NCCI edit?
A modifier should not be added simply to bypass an edit. The clinical circumstances and applicable coding rules must support separate reporting.
What is the difference between Modifier 25 and 24?
Modifier 25 addresses a significant, separately identifiable E/M service performed on the same day as another procedure or service. Modifier 24 addresses an unrelated E/M service performed during an applicable postoperative period.
Modifier 25 Quick Cheat Sheet
- E/M service performed on the same date as another procedure or service.
- E/M service is significant.
- E/M service is separately identifiable.
- E/M work is above and beyond the usual work associated with the procedure.
- Documentation supports the E/M service.
- Medical necessity is supported.
- Applicable payer and coding requirements have been reviewed.
Key Takeaways
Same Day
Modifier 25 is used when an E/M service is reported with another procedure or service on the same date.
Separate E/M Work
The E/M service must be significant and separately identifiable.
Documentation
The medical record must support the additional E/M work and applicable medical necessity.
Modifier 25 FAQs
What is Modifier 25 in medical billing?
Modifier 25 is used to report a significant, separately identifiable E/M service performed on the same day as another procedure or service when applicable requirements are met.
When should Modifier 25 be used?
It may be used when the E/M service is significant, separately identifiable and above and beyond the usual work associated with another service performed on the same date.
Does Modifier 25 mean two separate visits?
No. The services can occur during the same encounter. The issue is whether the E/M service is separately identifiable and significant.
Can Modifier 25 be used with every procedure?
No. The clinical circumstances, documentation, coding rules and payer requirements must support separate reporting.
Can Modifier 25 be used to override bundling?
Modifier 25 should not be used simply to override a bundling edit. The applicable coding edit and modifier rules must be reviewed.
What documentation is needed for Modifier 25?
Documentation should support the E/M service, the medical necessity and the significant, separately identifiable work performed beyond the normal work associated with the other service.
Why was my Modifier 25 claim denied?
Common reasons include insufficient documentation, the E/M being considered part of the procedure, failure to establish separate E/M work, an NCCI or payer edit, or payer-specific requirements.
Does Modifier 25 guarantee payment?
No. Correct modifier reporting does not guarantee payment. The claim must satisfy applicable coding, documentation, medical necessity and payer rules.
Official Resources
Always verify current Medicare and payer requirements before billing, correcting or appealing a claim.
Master Modifier 25
Learn how to identify, document, bill, audit and resolve Modifier 25 issues with practical medical billing examples and AR denial workflows.
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