Modifier 25 tells the payer that an evaluation and management (E/M) visit on the same day as a procedure or another service was significant and separately identifiable. It is one of the most used modifiers and one of the most common reasons for denials and audits. This article covers when it applies under Medicare's rules and how to document it.
What modifier 25 means
Every procedure payment already includes some E/M work: the routine evaluation before it, deciding to do it, and the usual follow-up. Modifier 25 says the visit went beyond that work, so it should be paid separately. It always goes on the E/M code, never on the procedure.
- 25
- Significant, separately identifiable E/M service on the same day as a minor procedure or other service
- 57
- Decision for surgery, used on the E/M when the decision is made for a major procedure
Minor procedures vs. major procedures
Medicare decides which modifier applies based on the procedure's global period:
- Minor procedures (0- or 10-day global): the decision to perform the procedure is included in its payment. A separate E/M is billable with modifier 25 only when it is significant and separately identifiable, beyond the decision to do the procedure and the usual pre-procedure work.
- Major procedures (90-day global): the E/M visit where the decision for surgery is made is billed with modifier 57, not 25. Other pre-operative visits that day are included in the surgery.
Modifier 25 can also be used with services that have no global period (indicator XXX), such as many injections and tests, when the E/M meets the same standard.
Two common myths
"The E/M needs a different diagnosis." It doesn't. Medicare's NCCI policy says the E/M and the minor procedure do not require different diagnoses. What matters is whether the E/M work was separate and significant.
"A new patient always gets an E/M." It doesn't. The fact that the patient is new is not enough by itself to bill an E/M on the same day as a minor procedure. The same rules apply to new and established patients.
Preventive visit and problem visit on the same day
If a problem comes up during a preventive visit, such as a Medicare Annual Wellness Visit or a preventive medicine visit, and it takes real additional work to evaluate and manage, bill the preventive service plus an office E/M (99202–99205 or 99211–99215) with modifier 25. A minor issue that needs no real additional work is part of the preventive visit and shouldn't be billed separately.
The problem visit may carry cost sharing even when the preventive visit doesn't, so tell the patient at the visit. Commercial payers set their own rules for same-day preventive and problem visits.
Modifier 25 and G2211
Medicare doesn't pay the G2211 add-on when the E/M has modifier 25, except when the same-day service is an Annual Wellness Visit, vaccine administration or another listed preventive service. See Billing the G2211 Add-On Code.
Documentation
- Document the E/M so it stands on its own: the problem addressed, the assessment and plan, and the medical decision-making or time.
- Keep the procedure note separate, or clearly separate the two parts of one note.
- A useful check: if the procedure hadn't been done, would this E/M still have been needed? If not, it's probably part of the procedure.
Modifier 25 is frequently reviewed by Medicare contractors and commercial payers. The documentation, not the modifier, is what supports payment.
Common reasons for denial
- The E/M only documents the decision to do a minor procedure and the routine pre-procedure exam
- Modifier 25 placed on the procedure code instead of the E/M
- Modifier 25 used for the decision for a major surgery, where modifier 57 applies
- An E/M billed only because the patient was new
- A minor issue during a preventive visit billed as a separate problem visit
- Payer-specific rules: some commercial plans review or reduce payment for E/M visits with modifier 25
Sources
- CMS, NCCI Policy Manual for Medicare Services 2026, Chapter I (sections D and E)
- AMA: Can physicians bill for both preventive and E/M services in the same visit?
- CMS Transmittal 13015, Change Request 13705: G2211 with certain Part B preventive services
If modifier 25 denials keep showing up on your remittances, our billing team can review them with you.