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Modifier 25

Definition

Modifier 25 is used when a significant, separately identifiable evaluation and management (E/M) service is provided on the same day as a procedure. The E/M service must have independent clinical significance and address a condition distinct from the procedure itself. Add modifier 25 to the E/M code to indicate the service warrants separate payment.

When to Use

  1. Patient comes in for routine preventive exam (99213) and acute problem identified requiring treatment (e.g., cerumen removal 69210)
  2. Established patient visit (99214) for diabetic management, then foot care procedure (11721 removal of warts)
  3. New patient comprehensive visit (99203) and minor surgical procedure same day (e.g., skin biopsy 11100)
  4. Pre-operative clearance E/M (99213) and minor procedure unrelated to surgery (e.g., vaccination 90658)

Documentation Requirements

Document distinct medical necessity in the chart. Show the E/M service evaluation in separate note section from procedure. If E/M is preventive and procedure is problem-focused, clearly separate the two. Include reason for visit, history of present illness, and examination findings. Time spent on E/M and procedure should be documented separately if billing higher-level codes.

Payer-Specific Rules

Payer Acceptance Common Denials Notes
Medicare Accepted when documented separately CO-59: Service/item not eligible for payment Deny if E/M documented as incidental. Require distinct documentation.
Aetna Accepted with modifier 25 CO-8: Services not covered May bundle if E/M is preventive and procedure is incidental to care.
United Healthcare Accepted when clinically distinct CO-4: Service/item billed during global period Strict on documentation. E/M must show separate clinical decision-making.
Cigna Accepted with proper documentation CO-59: Service/item not separately payable Bundle if E/M only addresses procedure post-op care.
Humana Accepted when medically necessary CO-8: Services denied based on plan Deny if only preventive E/M, procedure unrelated to complaint.
  • 59 – Use when modifier 25 is insufficient; bundle edit exists between codes.
  • XE – Separate encounter same day. Use when E/M from different encounter session.
  • 26 – Professional component. Use when billing E/M with split-billing service.

Common Denials

CARC Code Reason Primary Cause
CO-59 Service/item not separately payable No separate documentation for E/M service; insurer sees E/M as incidental to procedure.
CO-4 Service bundled in global period Modifier 25 applied but procedure has pre-operative E/M included in global package.
CO-151 Claim submitted without required supporting documentation Insufficient documentation proving E/M was distinct from procedure.

FAQ

Can I use modifier 25 with telehealth E/M?

Yes. If E/M is provided via telehealth (modifier 95) on same day as procedure, use both modifiers: 99213-25-95.

Does modifier 25 work with preventive care codes?

Yes, if you also provide problem-focused service. Document both separately. If only preventive service, do not use modifier 25.

What if the E/M and procedure are for the same condition?

Modifier 25 does not apply if E/M is pre-operative evaluation for the procedure. Use modifier 25 only when E/M is unrelated or only partially related.

Prevent These Denials

Reduce modifier 25 denials. Get a co-pilot to review your E/M documentation and bundle edit rules.

Related Resources

This reference is current as of 2026-03-23. Payer policies change. Always verify against the payer's latest policy documentation.
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