Modifier 25 tells a payer that the visit performed on a procedure day was significant work, separate from the procedure itself. Appending it is easy. Defending it happens in the note, and the record decides whether the E/M stands on its own. Two federal audits published in 2025 found that most reviewed same-day E/M services did not support the modifier.
What this covers
- Modifier 25 goes on the E/M code and nowhere else. It never attaches to a procedure code, and Medicare will not use it to pay for two E/M services on the same day by the same physician.
- A different diagnosis is neither required nor sufficient. The NCCI Policy Manual and the Medicare Claims Processing Manual both state the E/M and the procedure may share a diagnosis, so a second ICD-10 code does not create the separately identifiable service.
- The global period picks the modifier. Minor procedures (000 or 010) and XXX procedures take 25 on the E/M, a 90-day major procedure decided at the visit takes 57, and an unrelated E/M inside another procedure’s postoperative period takes 24.
- Both services have to be appropriately and sufficiently documented even though the documentation is not sent with the claim. A note that only makes sense next to the procedure fails the standalone test.
- MACs measure modifier 25 as a rate against specialty peers. High relative use, reviewed case by case and confirmed as inappropriate, is what triggers prepayment screens and documentation requirements.
The procedure already includes the decision to do it. Modifier 25 pays only for the work the procedure does not cover.why the same visit can be both bundled and billable
The modifier arrives on a claim as two characters, but it asserts clinical work: that the patient’s condition required a separately documented evaluation and management service beyond the work built into the procedure code. That assertion is accepted or rejected on the medical record.
What modifier 25 asserts, and what it does not
The CPT Professional codebook defines modifier 25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. CMS quotes that definition in the NCCI Policy Manual, Chapter 1, and adds that the E/M may relate to the same or a different diagnosis as the other procedure.
Three rules follow. The modifier goes on the E/M code, never the procedure. The E/M and the procedure may share a diagnosis, so a second diagnosis is not the test. And the service must be substantiated by documentation that meets the criteria for the E/M level billed.
The Medicare Claims Processing Manual, Publication 100-04, Chapter 12, section 30.6.6, carries the payer’s version: modifier 25 is used only on claims for E/M services, and only when the E/M is provided by the same physician or qualified nonphysician practitioner to the same patient on the same day as another procedure or service. The E/M must be above and beyond the procedure’s usual pre- and post-operative work.
The CPT entry itself closes one door. The note at the end of the definition says modifier 25 is not used to report an E/M service that resulted in a decision to perform surgery. That work belongs to modifier 57 when the procedure carries a 90-day global period.
The global period decides which modifier applies
Most modifier 25 denials are modifier-selection errors. The global period of the procedure, published in the Medicare Physician Fee Schedule database, sets the answer before any clinical judgment enters the picture.
| Situation | Correct modifier | Authority or rule |
|---|---|---|
| Significant, separately identifiable E/M on the same day as a minor procedure (000 or 010 global) or an XXX procedure | 25 on the E/M | NCCI Policy Manual, Chapter 1, section E(b) |
| E/M on the day of, or the day before, a 90-day major procedure, where the visit produced the decision to operate | 57 on the E/M | Medicare Claims Processing Manual, Chapter 12, section 30.6.6(C) |
| Unrelated E/M inside the postoperative period of a prior procedure | 24 on the E/M | NCCI Policy Manual, Chapter 1, section D |
| Two non-E/M procedures that are distinct from one another | 59 or an X modifier (XE, XS, XP, XU) on the procedure | NCCI Policy Manual, Chapter 1, section E(d) |
| A second E/M on the same day by the same physician | Not payable through modifier 25 | Medicare Claims Processing Manual, Chapter 12, section 30.6.6(B) |
Two payer rules sit inside that table. The manual states that Medicare Administrative Contractors may not permit modifier 25 to generate payment for multiple E/M services on the same day by the same physician, whatever the CPT definition says. And contractors may not pay an E/M billed with modifier 57 against a procedure with a 0-day or 10-day global period. Choose the wrong modifier on either line and the record cannot cure the denial.
Modifier 25 is not a substitute for modifier 59. CPT states that modifier 59 should not be appended to an E/M service, and points back to modifier 25 for a separate E/M alongside a non-E/M service. The decision rule: a visit takes 25, 57 or 24; a procedure that bundles into another procedure takes 59 or an X modifier, on the procedure.
Both services must be documented, submitted or not
The Claims Processing Manual is direct about the record. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented in the patient’s medical record to support the claim, even though the documentation is not required to be submitted with the claim. Not submitted is not the same as not required.
What counts as significant is set by the E/M level billed. The American Medical Association’s issue brief on modifier 25 explains that CPT treats a significant, separately identifiable E/M as one substantiated by documentation that satisfies the criteria for the E/M service being reported. There is no separate standard for modifier 25, only the standard for the E/M code chosen.
The same brief offers three questions that map to the coding guideline. Answer yes to all three and the modifier is consistent with CPT.
- Did the physician perform and document the level of medical decision making or total time needed to report a problem-oriented office or outpatient E/M service for that complaint or problem?
- Could the work to address that complaint or problem stand alone as a reportable service?
- Did the physician perform extra work above and beyond the typical pre-operative or post-operative work of the procedure code?
When time, rather than medical decision making, supports the E/M level, the note must state the time spent on the E/M separately from the procedure. A general line about minutes in the room does not carry an E/M level on a procedure day.
The Claims Processing Manual names three situations where the record is checked even without a broader review: inpatient dialysis services, pre-operative critical care billed on the date of the procedure, and a targeted review of a provider or group whose modifier 25 use runs high against peers. In each case the documentation duty is the same one that applies every day.
Note patterns that fail review
The failures cluster, and the same handful shows up in the OIG samples and in MAC review.
- The decision to perform. Evaluating the problem and deciding to do the procedure is inside the procedure payment. The NCCI Policy Manual states the decision to perform a minor surgical procedure is included in the payment for that procedure and shall not be reported separately as an E/M service.
- The new-patient assumption. Being new to the practice is not enough by itself to justify a same-day E/M with a minor procedure. Newness does not create separate work.
- The template wrapper. An electronic record that wraps an E/M shell around a procedure template produces the look of a separate visit without the substance. A reviewer reading only the E/M section still has to find a distinct problem, its findings, and its management decision.
- The second diagnosis doing the work. Because a different diagnosis is neither required nor sufficient, an added ICD-10 code that is not tied to documented evaluation does not rescue the line. It can weaken the claim instead.
- The merged note. When the E/M and the procedure are written as one continuous entry, a reviewer cannot separate them. OIG found this in its injection review, where providers documented the injection assessment and the injection itself in one entry with no distinct E/M section.
A MAC example makes the line concrete. Palmetto GBA publishes a modifier 25 lookup with a correct case and an incorrect one. In the incorrect case, a physician billed 99213 with modifier 25 alongside a skin and subcutaneous debridement (11042) to reflect the time, examination and decision making that led to the debridement. Nothing else was addressed at the encounter. Palmetto’s answer is to submit only the procedure: the decision to debride is already inside 11042.
How payers score the pattern across claims
A single claim is reviewed on its documentation. A pattern is reviewed on data, and the Claims Processing Manual describes the sequence. When a MAC has reviewed the data and found an individual or group has high use of modifier 25 compared with other physicians, done a case-by-case review confirming the use was inappropriate, and educated the practice, it may impose prepayment screens or documentation requirements on that provider or group. Relative use is the trigger.
Federal audits show what a sustained pattern costs. In a report issued in December 2025, the HHS Office of Inspector General reviewed podiatrists’ E/M claims billed with modifier 25 and found that 44 of 100 sampled claims did not comply with Medicare requirements. OIG estimated that about $39.6 million of the $222.5 million paid for the audit period did not comply, and CMS concurred with the recommendation to weigh additional oversight.
A second 2025 OIG report looked at same-day E/M services with intravitreal injections. Providers billed a same-day E/M with modifier 25 for 42 percent of the injections in the audit period, and of 24 sampled records, 22 did not support the modifier. Medicare paid $124 million for those E/M services, and OIG recommended recovery of up to $123,955,176.
Professional societies push back on how those numbers are read. The American Academy of Ophthalmology notes that the follow-up Supplemental Medical Review Contractor review of the same services found a 7 percent error rate, far below what the OIG sample implied. The disagreement does not change the local rule: payers score the rate, and it is visible in your billing data long before a contractor raises it.
Commercial payers act on the same modifier with their own tools. The AMA issue brief lists the common ones: flagging claims for pre-payment validation, requiring documentation with the claim, reducing payment for the second code to account for perceived overlap, and carving the problem-oriented E/M out of a preventive service payment.
A pre-submission check for a same-day E/M
The order of the checks matters. Work from the code outward, then confirm the note can carry it.
Look up the procedure in the Medicare Physician Fee Schedule database and read the global indicator. 000, 010 or XXX points to modifier 25, 090 points to 57 for the decision visit, and a 0-day or 10-day global rules out 57 entirely.
If the issue is the visit, the modifier is 25, 57 or 24. If the issue is a procedure that bundles into another procedure, the modifier is 59 or an X modifier, and it goes on the procedure.
Cover the procedure note and read the E/M section alone. It needs a distinct problem, relevant findings, and its own assessment and plan. If it only makes sense as a lead-in to the procedure, it fails.
The procedure note carries the indication, technique, consent and response. The E/M note carries the separate problem. Keep them in distinct sections.
The billed E/M level has to match the documented medical decision making or time for the separate problem, not the complexity of the procedure.
Track modifier 25 use as a share of same-day procedure visits by clinician and compare it with peers. A rate that rises on its own is the signal a reviewer will also see.
A practice that runs this check before submission spends its review time on the claims that need it. Where the same-day pattern is common, a comprehensive chart audit sampling across clinicians will show whether the issue is one or two templates or a habit the group shares. The coding fundamentals sit in our medical coding overview, and the same-day billing workflow is covered under medical coding and billing.
Modifier 25 questions practices ask
No. The NCCI Policy Manual and the Medicare Claims Processing Manual both state that a different diagnosis is not required, and the E/M and the procedure may share one. A second diagnosis code is also not sufficient, because the test is the documented work, not the diagnosis linkage. Reviewers look for a distinct problem, its findings, and a separate management decision.
On the E/M code, never the procedure code. Medicare’s manual states that modifier 25 should only be used on claims for E/M services. NCCI guidance says modifiers 24, 25 and 57 should be appended only to an E/M code and never to a surgery code. Appending it to the procedure is a common cause of first-pass denials and does not protect the E/M.
Not under Medicare. The Claims Processing Manual states that contractors may not permit modifier 25 to generate payment for multiple E/M services on the same day by the same physician, whatever the CPT definition says. The modifier separates an E/M from a procedure, not two visits. Check the payer’s policy before submitting that combination.
When the visit produced the decision to perform a major procedure, defined by a 90-day global period, performed that day or the next. Modifier 25 fits minor procedures with a 000 or 010 global period and procedures with no global concept. Contractors may not pay an E/M billed with modifier 57 against a procedure with a 0-day or 10-day global period.
A record that supports both services. The E/M has to meet the criteria for the level billed, with its own problem, findings and plan, and the procedure has to be documented too. Those requirements apply even though the documentation is not submitted with the claim. A note that only reads as a preamble to the procedure does not meet the separately identifiable standard.
No. NCCI guidance states that a patient being new to the provider is not sufficient, on its own, to justify a separate E/M on the same day as a minor procedure, because the decision to perform the procedure is bundled regardless of patient status. The E/M stands only on work above and beyond the procedure’s usual pre- and post-operative care.
After reviewing the data, confirming case by case that the use was inappropriate, and educating the practice, a contractor may impose prepayment screens or documentation requirements on that provider or group. That sequence is set out in the Medicare Claims Processing Manual. Relative use against peers is the starting signal, and it can be measured inside the practice before a contractor raises it.
The bottom line
Modifier 25 asks a payer to pay for a visit the procedure would otherwise absorb, and payers test that request against the record. The definition is settled: significant, separately identifiable, above and beyond the procedure’s own work, on the E/M code and never the procedure. A practice that documents the visit as a complete service, picks the modifier the global period calls for, and watches its own rate will not need an auditor to explain which note was thin.
Is your same-day E/M documentation ready for a records request?
Send us a sample of same-day E/M and procedure claims with the notes behind them. Our team will score each against the significant and separately identifiable test, flag the lines a reviewer would question, and show you the pattern by clinician.
Request a free modifier 25 documentation reviewThis article describes general Medicare and coding practice rather than legal advice, and payer policies on modifier 25 vary, so confirm the current NCCI Policy Manual, the Medicare Claims Processing Manual and each payer’s own policy before submitting a same-day E/M claim.
