E/MHigh audit riskCPT

CPT Modifier 25

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

Source: AMA CPT / CMS HCPCS Level II definitions. Maintained by the D3rx Clinical Billing Team.

What modifier 25 means

Modifier 25 is appended to an E/M service reported on the same day as a minor procedure (000- or 010-day global) or other service when the E/M is significant and separately identifiable from the inherent pre- and post-service work of that procedure. The documentation must support a distinct, medically necessary E/M above and beyond the usual work bundled into the procedure.

When to use it

A patient is evaluated for a problem and a minor procedure is also performed the same day — for example, a problem-focused visit during which a lesion is destroyed or a joint is injected — and the E/M addressed a separate or significant issue.

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Documentation checklist

The record should support every item below before you append modifier 25.

  • A distinct history, exam, and/or medical decision making beyond the procedure itself
  • The significant, separately identifiable nature of the E/M
  • Medical necessity for the E/M independent of the procedure
  • (A separate diagnosis is not required by CPT but reinforces the claim)

Do NOT use modifier 25 when

  • The only service was the decision to perform the minor procedure (that work is bundled)
  • No significant, separately identifiable E/M actually occurred
  • The E/M is the decision for major (90-day) surgery — use modifier 57
  • Routine pre-procedure evaluation already included in the procedure

Common denial reasons

  • Payer edits bundle the E/M into the same-day procedure
  • Documentation does not support a separate, significant E/M
  • Overuse flags audits (several large commercial payers scrutinize modifier 25)

Denial codes you may see with modifier 25

CO-97CO-4CO-50

How to appeal a modifier 25 denial

Submit the chart note and highlight the separately identifiable history, exam, and MDM that go beyond the minor procedure's inherent work. Point out that CPT does not require a distinct diagnosis, and where one exists, identify it; emphasize the medical necessity of the E/M itself.

Payer notes

CPT does not require a different diagnosis for modifier 25, but one supports the claim. Some commercial payers have proposed notes submission or reduced payment for 25 — policies vary and change, so verify the current payer rule.

Related & commonly confused modifiers

Modifier 57Modifier 24Modifier 59Modifier 27

Where modifier 25 is used

  • E/M with minor procedures (10060, 17110, 20610, 96372)
  • Preventive visit plus a separate problem-oriented E/M
  • Office E/M (99202–99215)

Look up these codes & their 2026 Medicare rates

100601711020610963729920299215

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Medical billing disclaimer

Modifier definitions follow standard AMA CPT and CMS HCPCS Level II guidance and are for educational reference. Payer policies, billing formats, and coverage rules vary and change. Always verify the current rule with the specific payer before submitting. D3rx is not responsible for claim outcomes.