Modifier 25: Is the E/M Separately Billable?

Modifier 25 is a claim you are making, not a formatting step. Appending it asserts that the evaluation and management service you performed on the same day as a procedure was significant, separately identifiable, and above and beyond the pre-procedure, intra-procedure and post-procedure work already paid for inside the procedure code. If the record does not show all three, the modifier is not merely unnecessary — it is the assertion that made an unsupported payment happen.

This page is about making and documenting that call on an individual encounter: what the test actually is, when a different modifier is the correct one, what your MAC will and will not ask you to prove, and how the decision differs from the one you make with modifier 59.

Verified against the Medicare National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, 2026 edition (revision date 1 January 2026), Chapters I and XI; the Medicare Claims Processing Manual (Pub. 100-04) Chapter 12 §§30.6.6 and 40; and Chapter 23 §20.9.1.1. CPT codes, descriptions and other data are copyright the American Medical Association. Individual MACs publish their own edits, local coverage articles and targeted review activity; where a rule below is contractor-dependent it is flagged.

What the Modifier Asserts

The NCCI Policy Manual Chapter I quotes the CPT Professional codebook definition of 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,” and explains its function:

“Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).”

Three things are already settled by that paragraph:

Modifier 25 goes on the E/M code, never on the procedure.
A different diagnosis is not required. The Medicare Claims Processing Manual Chapter 12 §30.6.6 says the same thing independently: “Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service.”
A different diagnosis is not sufficient either. Nothing in either source makes a second diagnosis code a qualifying criterion; the test is about work, not about diagnosis linkage. Appending a second ICD-10 code to make a claim pass an edit, without corresponding documented work, is the classic finding.

The Test, and What Fails It

The NCCI Policy Manual states where the modifier is available and, more usefully, what it can never cover:

“Modifier 25 may be appended to E&M services reported with minor surgical procedures (with global periods of 000 or 010 days) or procedures not covered by Global Surgery Rules (with a global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.”

That last sentence is the one that decides most disputed claims, and it is stricter than many practices assume. The decision to perform a minor procedure is not separately billable. Not for a new patient, not for a self-referred patient, not because the patient had never been evaluated for the problem before. If the entire E/M content of the visit was working out whether to do the procedure, there is no modifier 25.

The Medicare Claims Processing Manual Chapter 12 §40 puts the same principle in the global-surgery context: where the decision to perform a minor procedure is typically made immediately before the service, “it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.”

What survives the test is E/M work that would have been done, and documented, whether or not the procedure happened — a separate problem addressed, a distinct history and examination driving a distinct assessment and plan, a management decision unrelated to the procedure’s own pre- and post-work.

Which Modifier Is Actually Correct: A Decision Table

Most modifier 25 denials are really modifier-selection errors. The global period of the procedure determines the answer.

Situation	Correct modifier	Authority
Significant, separately identifiable E/M on the same day as a minor procedure (000 or 010-day global) or an XXX procedure	25 on the E/M	NCCI Policy Manual ch. I §E(b)
E/M on the day of, or the day before, a procedure with a 90-day global period, where the visit resulted in the decision to perform the procedure	57 on the E/M	CPM ch.12 §30.6.6(C)
E/M on the day of, or the day before, a procedure with a 0 or 10-day global period, where the visit resulted in the decision to perform it	Neither — not separately payable	CPM ch.12 §30.6.6(C): MACs “may not pay” an E/M billed with modifier 57 in this situation; NCCI bars modifier 25 for decision-to-perform work
Unrelated E/M during the postoperative period of another procedure	24	NCCI Policy Manual ch. I §E — 24 is a global surgery modifier associated with NCCI PTP edits
Two non-E/M procedures that are distinct from one another	59 or an X{EPSU} modifier on the procedure	CPT definition of modifier 59, quoted in NCCI ch. I §E(d)
A second E/M on the same day by the same physician	Not payable via modifier 25	CPM ch.12 §30.6.6(B)

On that last row, the Claims Processing Manual is explicit and overrides the CPT convention: “A/B MACs (B) may not permit the use of CPT modifier ‘-25’ to generate payment for multiple evaluation and management services on the same day by the same physician, notwithstanding the CPT definition of the modifier.” This is one of the places where following CPT alone produces a non-compliant Medicare claim.

What Your MAC Will Ask For

Medicare’s default posture on modifier 25 is more permissive than practices expect, and knowing where the exceptions are is what lets you allocate documentation effort sensibly. Per CPM Chapter 12 §30.6.6(B):

“If the physician bills the service with the CPT modifier ‘-25,’ A/B MACs (B) pay for the service in addition to the global fee without any other requirement for documentation unless one of the following conditions is met…”

The three conditions are:

Inpatient dialysis services (the manual names CPT codes 90935, 90945, 90947 and 93937): the physician must document that the service was unrelated to the dialysis and could not have been performed during the dialysis procedure.
Preoperative critical care billed on the date of the procedure: the diagnosis must support that the service is unrelated to the performance of the procedure.
Targeted review. Where a MAC has conducted a specific medical review process, determined from the data that an individual or group has high use of modifier 25 relative to peers, done a case-by-case record review confirming the use was inappropriate, and educated the individual or group, it may then impose prepayment screens or documentation requirements on that provider or group.

Note what condition 3 describes: a sequence of data analysis, record review, education, and only then prepayment edits. A rising modifier 25 rate relative to specialty peers is the trigger, and it is measurable inside your own practice long before a contractor raises it. The equivalent process exists for modifier 57 in the same paragraph.

The documentation requirement itself is unconditional even where no review is under way. The manual: “Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.” Not submitted is not the same as not required.

Why the Bar Sits Where It Does

The enforcement history is specific and worth knowing, because it explains why contractors treat this modifier as a risk area rather than a routine one. The HHS Office of Inspector General reviewed the modifier in Use of Modifier 25 (OEI-07-03-00470, November 2005), sampling 450 claims billed in calendar year 2002 and having certified professional coders assess them. The findings:

35% of claims using modifier 25 that Medicare allowed in 2002 did not meet program requirements, resulting in $538 million in improper payments — because the E/M services were not significant, separately identifiable and above and beyond the usual pre- and post-operative care, or because the claims failed basic Medicare documentation requirements.
A further tranche failed program requirements without necessarily causing improper payment — notably, attaching modifier 25 to an E/M claim when no other service was performed that day at all. Reflex appending is itself a compliance defect.
Carrier oversight was limited, with more than a third of carriers conducting no oversight of the modifier.

Context matters when reading those numbers: in calendar year 2002, Medicare allowed $1.96 billion across approximately 29 million claims carrying modifier 25. This is a high-volume, high-aggregate-dollar modifier, which is precisely why a percentage error rate translates into headline figures — and why a practice with an outlier rate is visible in claims data without anyone reading a chart.

Concrete Scenarios from the NCCI Manual

NCCI Policy Manual Chapter XI works through several situations where modifier 25 is and is not correct. These recur constantly in outpatient and infusion settings.

Drug and Chemotherapy Administration

CPT codes 96360–96379 and 96401–96425 “have been valued to include the work and practice expenses of CPT code 99211.” Consequently 99211 is not reportable with drug or chemotherapy administration codes. Other non-facility E/M codes (the manual gives 99202–99205 and 99212–99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E/M service.

Facility E/M Codes and Drug Administration

Because providers must not report drug administration services in a facility setting, a facility-based E/M code (the manual gives 99281–99285) is not reportable by a provider with a drug administration code “unless the drug administration service is performed at a separate patient encounter in a non-facility setting on the same date of service,” in which case modifier 25 is appended to the E/M.

Under the OPPS, the rule runs differently for the hospital: hospitals may report drug administration and chemotherapy administration services with facility-based E/M codes (99281–99285, G0463) if the E/M service is significant and separately identifiable, with modifier 25 appended to the E/M code. The professional-claim answer and the facility-claim answer are not the same for the same encounter.

Vaccines and Immunisations

The same 99211 rule applies: 99211 is not separately reportable with vaccine administration codes 90460–90474, 90480, 90481 or G0008–G0010. Other E/M codes are separately reportable with a vaccine administration code if the E/M service is significant and separately identifiable, with modifier 25 appended. Where one or more immunisations and a significant, separately identifiable E/M service are rendered on the same date, the immunisation administration code and the E/M with modifier 25 may both be reported. If the patient returns on another day solely to receive another immunisation, only the immunisation administration code is reported.

How Modifier 25 Interacts with NCCI Edits

Modifier 25 is one of the NCCI PTP-associated modifiers — listed in the “global surgery modifiers” group (24, 25, 57, 58, 78, 79) in NCCI Policy Manual Chapter I §E and in the Claims Processing Manual Chapter 23 §20.9.1.1(A). That means it can bypass a procedure-to-procedure edit, subject to the Correct Coding Modifier Indicator on that specific edit:

CCMI 0 — an NCCI PTP-associated modifier is not allowed and will not bypass the edit. The Column Two code is not eligible for payment even if a modifier is appropriately appended.
CCMI 1 — a modifier is allowed and may bypass the edit if appropriately appended.
CCMI 9 — use of NCCI PTP-associated modifiers is not specified; used for code pairs whose deletion date equals their effective date.

The overriding rule sits above all of that, and it is the sentence that turns a coding question into a compliance one:

“Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier shall not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use.”

Modifier 25 Versus Modifier 59: The Line Between Them

“Modifier 59 vs 25” is a question people ask because both modifiers exist to say “these were separate services.” They are not substitutes, and CMS resolves the overlap by rule rather than by judgment.

	Modifier 25	Modifier 59 (and X{EPSU})
Goes on	The E/M code	A non-E/M procedure code
Never goes on	The procedure	An E/M service — CPT: “Modifier 59 should not be appended to an E/M service”
What it establishes	The E/M was significant, separately identifiable, and above and beyond the procedure’s inherent work	Two procedures were distinct — different encounter, different anatomic site, different practitioner, or non-overlapping service
Relationship to diagnosis	Different diagnosis neither required nor sufficient	Different diagnosis neither required nor adequate criteria
If used on the wrong code type	—	The MAC “must process the claim as if the modifier were not present” (CPM ch.23 §20.9.1.1(B))

The Claims Processing Manual Chapter 23 §20.9.1.1(B) lists E&M services among the codes with which modifiers 59, XE, XP, XS and XU shall not be used, and instructs MACs to process such claims as though the modifier were absent. The CPT definition of modifier 59 says the same thing and points the reader back: “To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

The practical decision rule: if the thing you are trying to protect is a visit, the answer is 25 (or 57, or 24). If the thing you are trying to protect is a procedure, the answer is 59 or one of the X modifiers. The full defensibility analysis for the procedure side is in the companion guide on modifier 59 and the X{EPSU} subset.

Documentation That Holds Up

There is no CMS-prescribed template for a modifier 25 note. What the sources require, read together, is that the record independently supports both services. In practice that means:

Write the E/M as a standalone note. The reviewable question is whether, with the procedure note removed, what remains still reads as a medically necessary evaluation and management service. A note that only makes sense as a preamble to the procedure fails.
Separate the assessment and plan. Address the separately identifiable problem explicitly, with its own findings and its own management decision.
Do not rely on a second diagnosis code to do the work. It is neither required nor sufficient, and an unsupported second code is worse than none.
Do not document the decision to perform the minor procedure as the E/M. That work is inside the procedure code by rule.
Document the procedure fully too. The manual requires both services to be appropriately and sufficiently documented; OIG’s findings included claims that failed on basic documentation rather than on the significance test.
Check the global indicator before choosing the modifier. 000/010/XXX → consider 25; 090 → consider 57; the wrong choice on a 90-day global is a denial the record cannot cure.
Audit your own rate. Modifier 25 frequency as a proportion of eligible encounters, by clinician and by procedure family, is the same signal a MAC uses to open a targeted review.

Non-Medicare Payers

Everything above is Medicare fee-for-service policy. Commercial payers and Medicaid programmes set their own rules for same-day E/M and procedure reporting, and several have adopted payment reductions or documentation-submission requirements for modifier 25 that have no Medicare analogue. We have not verified any specific commercial payer’s current policy for this page, and you should not assume the Medicare position carries over. Read the individual payer’s reimbursement policy, and check your MAC’s own local articles for Medicare edits layered on top of the national rules described here.

Modifier 25: Deciding Whether the Same-Day E/M Is Separately Identifiable

Ask about Modifier 25: Deciding Whether the Same-Day E/M Is Separately Identifiable