Modifier 25 billing guide: when to use it and how to document it

Modifier 25 is appended to an evaluation and management (E/M) code when the same physician or other qualified health care professional provides a significant, separately identifiable E/M service on the same day as a procedure or other service. It goes on the E/M code, never on the procedure. The key test is whether the documentation shows work beyond the usual pre-procedure and post-procedure evaluation that is already included in the procedure. If the visit was only to decide on and perform the procedure, the E/M is not billed separately.

Modifier 25 is one of the most used modifiers in outpatient billing, and one of the most reviewed. This guide covers when it applies, when it does not, how to document it, and the payer issues practices run into.

What every procedure already includes

Under Medicare's global surgery rules, procedures have a global period of 0, 10 or 90 days. Minor procedures (0 or 10 day global) include the routine evaluation right before the procedure: reviewing the problem, examining the area, deciding to proceed and getting consent. Medicare also states that a patient being new to the provider is not by itself enough to justify a separate E/M on the same day as a minor procedure.

For major procedures with a 90-day global period, the decision for surgery made on the day before or the day of surgery is reported with modifier 57, not 25.

So the question for modifier 25 is always the same: did the provider do meaningful E/M work that would have been needed even if the procedure had not been performed?

When modifier 25 applies and when it does not

Common situations by specialty

Primary care

The most frequent case is a preventive visit combined with a problem visit. A patient comes for an annual physical (99381 to 99397 depending on age and new or established status) and also needs a medication adjustment for hypertension or a workup for new abdominal pain. Bill the preventive code and the problem-oriented E/M with modifier 25. Only the problem-focused portion counts toward the E/M level, and the history and exam that were part of the preventive service should not be counted twice. Medicare does not cover routine preventive physicals, so for Medicare patients the pairing is usually the annual wellness visit (G0438 or G0439) or the initial preventive physical exam (G0402) with a problem E/M. Patients may owe cost sharing on the problem visit even when the preventive service is covered in full, so it helps to explain that at the visit. See our family practice billing page for more on primary care coding.

Dermatology

Dermatology uses modifier 25 often because visits commonly include both procedures and medical management. A full skin exam with management of psoriasis plus destruction of actinic keratoses (17000) can support an E/M with modifier 25 when the psoriasis management is documented separately. If the patient came in only for the lesion destruction, it does not. Our dermatology billing page covers other common edits in that specialty.

Urgent care

Urgent care visits often combine a full evaluation with a minor procedure such as a laceration repair, splinting or incision and drainage. Modifier 25 is appropriate when the evaluation addresses more than the procedure site, for example ruling out a fracture or concussion. Our urgent care billing page covers that setting.

Injections and drug administration

Many practices pair a therapeutic injection (96372) or vaccine administration with an E/M. If the provider evaluated and managed a problem, the E/M can be billed with modifier 25. If the patient came only for the injection or vaccine, bill the administration and the drug without the E/M.

Does modifier 25 need a different diagnosis?

No. CPT states that a different diagnosis is not required for the E/M. A patient evaluated for worsening knee pain who also receives an injection can have the same diagnosis on both lines if the evaluation went beyond the usual pre-procedure work. That said, when the E/M addressed a different problem, listing that diagnosis first on the E/M line makes the separate work clearer to the payer.

How to document a separately identifiable E/M

An auditor should be able to read the note and see two services. Good habits:

• Document the problem-oriented work in its own section, or clearly label which parts of the note relate to the E/M
• Show the medical decision making for the separate problem: data reviewed, risk of management, prescription drug changes, orders
• Write a separate procedure note with indication, consent, technique, findings and any complications
• Link each diagnosis to the right service on the claim
• Select the E/M level from medical decision making or total time that excludes the time spent on the procedure

A generic statement like "separately identifiable E/M performed" without supporting detail does not hold up in a review.

G2211 and modifier 25 for Medicare

Medicare pays add-on code G2211 for the complexity tied to ongoing longitudinal care with office and outpatient E/M visits. Since January 2025, Medicare allows G2211 when the office E/M is billed with modifier 25 only if the other same-day service is an annual wellness visit, a vaccine administration, or a Medicare Part B preventive service furnished in the office. When the modifier 25 E/M is billed with a procedure such as a joint injection, G2211 is not payable. Check your MAC's current guidance before billing it, and check commercial payer policies separately.

Payer reviews and audit risk

The HHS Office of Inspector General has reviewed modifier 25 use in the past and found claims where the E/M was not significant and separately identifiable. Some commercial payers also run their own reviews, ask for records on E/M claims with modifier 25, or have announced payment policies that affect these claims. Policies change, so read each major payer's current reimbursement policy at least once a year.

Patterns that draw attention:

• Modifier 25 on nearly every E/M billed with a procedure
• One provider using modifier 25 far more often than peers in the same specialty
• E/M levels that look the same regardless of the problem
• Copy-forward notes where the E/M section is identical across visits

A periodic coding review of a sample of modifier 25 claims by provider shows whether documentation supports the pattern before a payer asks.

Common modifier 25 mistakes

• Putting modifier 25 on the procedure code instead of the E/M code
• Using modifier 25 when the visit was scheduled only for the procedure
• Using 25 instead of 57 for the decision for a major surgery
• Billing an E/M during a global period for routine postoperative care (modifier 24 is for unrelated E/M services during the postoperative period)
• Counting the preventive history and exam again toward the problem E/M level
• Leaving modifier 25 off when it is supported, which causes the E/M line to deny as bundled

How SFA can help

Our coders review modifier 25 claims against the documentation during charge review, and our billing compliance team can look at a sample of claims by provider to show where the pattern is supported and where it needs work. If you want a second look, a free practice audit is a simple start: we review your billing and walk you through where revenue may be slipping.

Frequently asked questions

Does modifier 25 go on the E/M code or the procedure code?

On the E/M code. Modifier 25 tells the payer that the E/M was a significant, separately identifiable service performed on the same day as the procedure or other service.

Can I bill a preventive visit and a sick visit on the same day?

Yes, when the provider addresses a problem that needs additional work beyond the preventive service. Bill the preventive code and the problem E/M with modifier 25, and do not count the preventive history and exam toward the problem E/M level.

What is the difference between modifier 25 and modifier 57?

Modifier 25 is for a separate E/M on the same day as a minor procedure or other service. Modifier 57 is for the E/M where the decision for a major surgery with a 90-day global period is made, on the day before or the day of surgery.