CPT Modifier · E/M

Modifier 25

Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service

✅ When to Use Modifier 25

When a separately identifiable E/M service is performed on the same day as a procedure. The E/M must go beyond the typical pre/post work of the procedure.

⛔ When NOT to Use Modifier 25

Do NOT use if the E/M is the routine evaluation leading to the procedure. The key question: would this E/M have been billed even if no procedure was done?

📋 Documentation Requirements

Separate HPI, exam, and MDM for the E/M service. The medical record must clearly show the E/M was above and beyond the procedure evaluation.

Coding Tips for Modifier 25

Real-world specialist guidance from the PayerReady Medical Coding Team, including audit triggers, denial patterns, and payer policy variations.

OIG audit target every year. Modifier 25 means a "significant, separately identifiable E/M service" was performed on the same day as a procedure with a global period. The E/M must stand alone, document a separate HPI, exam, and MDM that goes beyond the pre/intra/post-procedure work bundled into the procedure.

Common denial trigger: Anthem, Cigna, and UHC all run automated 25 audits. If chart only documents the procedure plus a brief follow-up note, expect a CO-97 bundling denial. Best defense is two distinct progress notes or a clearly separated E/M section.

50% payment reduction does NOT apply to modifier 25, only to bilateral modifier 50. The E/M is paid at 100% of the fee schedule; the procedure is paid per its own status indicator.

Modifier 25 FAQ

What does modifier 25 mean? +

Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service

When should I use modifier 25? +

When a separately identifiable E/M service is performed on the same day as a procedure. The E/M must go beyond the typical pre/post work of the procedure.

When should I NOT use modifier 25? +

Do NOT use if the E/M is the routine evaluation leading to the procedure. The key question: would this E/M have been billed even if no procedure was done?

What documentation is required for modifier 25? +

Separate HPI, exam, and MDM for the E/M service. The medical record must clearly show the E/M was above and beyond the procedure evaluation.