Use modifier 25 when an E/M service is performed on the same day as a procedure, a preventive medicine service, or other medical service or procedure. Use our quick reference sheet and audit tool to determine when to use modifier 25, and which code to append it to. Using them consistently will help practices be reliable in their determinations and provide support in payer audits. Determining if there is a separate E/M is often a judgement call. Reasonable coders and practitioners can disagree.

• Modifier 25 | Audit Tool
• Using Modifier 25 | Reference Sheet

A minor surgical procedure is a procedure with 0 or 10 global days. E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure, unless it is separate and distinct.

Medicare says: Per CCI (chapter 11, Letter R.):

“The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.”

Use modifier 25 on an E/M service when evaluation of the patient’s condition was separate and distinct from the procedure.

CPT® definition

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: It may be necessary to indicate that on the day a procedure or service identified by a CPT® code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59 [1]

[1] 2022 CPT® Professional Edition, American Medical Association, page 917