When a patient receives an Evaluation and Management (E/M) service and a procedure on the same day, a special marker is needed in professional fee billing. This marker is Modifier 25, which is attached to the E/M code on the claim form. Its correct application ensures appropriate reimbursement by signifying that the E/M service was a distinct and billable service, not routine pre- or post-service work. Many procedures inherently include a certain level of pre- and post-service work, and without Modifier 25, the payer would assume the E/M service was part of the procedure’s bundled payment.
The Definition and Core Criteria
The American Medical Association’s Current Procedural Terminology (CPT) defines 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.” This definition establishes two fundamental criteria for appropriate use. First, the E/M service must be “significant,” meaning the work performed goes above and beyond the typical pre-procedure work included in the procedure’s payment. This significance is often determined by the complexity of the medical decision-making involved.
Second, the E/M service must be “separately identifiable,” meaning the documentation clearly supports the E/M as a distinct service from the procedure. Payment for any procedure, especially minor ones, includes allowances for preparing the patient and providing brief instructions. Therefore, the E/M service must justify its own billing separate from the payment bundled into the procedure code. Simply performing a procedure does not automatically allow reporting an E/M service with Modifier 25 unless both core criteria are satisfied.
The E/M service may be prompted by the same underlying condition that led to the procedure, so different diagnoses are not strictly mandated. However, the service must still represent a level of work that exceeds the routine preparation and follow-up associated with the procedure. When significance and separate identifiability are met, the modifier is appended to the E/M code (e.g., CPT codes 99202–99215) to indicate that the documentation supports a separate payment.
Establishing Separate Identifiability
The concept of “separately identifiable” is the most scrutinized aspect of Modifier 25 use and requires careful clinical reasoning. To prove the E/M service was distinct, the provider must demonstrate that the patient’s condition required an E/M service that was not a prerequisite component of the procedure. A common qualifying scenario occurs when a patient presents for a scheduled procedure, but a new, acute problem is discovered or reported during the visit that requires a full E/M workup. For example, a patient scheduled for a routine joint injection might mention new, sudden-onset chest discomfort requiring a separate, time-consuming evaluation before the injection can proceed.
Separate identifiability can also be established when the E/M addresses a different condition than the one treated by the procedure, or a different aspect of the same condition requiring extensive, independent assessment. Even with the same diagnoses, the E/M must involve a medical necessity distinct from the necessity of the procedure itself. The work must be performed and documented before the decision to perform the procedure was finalized, or it must address an entirely unrelated medical issue. The E/M portion must stand alone as a medically necessary service that would have been provided even if the procedure had not been performed that day.
Documentation Requirements for Audits
The medical record must clearly substantiate the use of Modifier 25 and demonstrate a distinct, medically necessary E/M service for audit purposes. This requires separate notation of the history, examination, and medical decision-making (MDM) related to the E/M service. The E/M documentation should be a complete record that satisfies the criteria for the reported E/M code level, not simply a preamble to the procedure note.
The record must clearly state the distinct chief complaint or reason for the E/M service, especially if it differs from the reason for the procedure. Physicians should avoid combining the E/M and procedure documentation into a single, merged entry, which makes separation difficult for auditors. Furthermore, the E/M documentation should indicate that the work was performed and completed before the decision to perform the procedure was made, or that the E/M was entirely unrelated to the procedure. Clear, concise documentation is the strongest tool to prove the E/M was significant and separately identifiable.
Relation to Global Surgical Periods
Modifier 25 is applied in the context of procedures that have an assigned global surgical period, particularly those considered minor with a 0-day or 10-day global period. The global period concept includes all necessary services routinely furnished by the provider before, during, and after a procedure. For minor procedures, the payment bundles in the usual pre-operative assessment, the procedure itself, and typical post-operative care.
The decision to perform a minor surgical procedure is included in the payment for the procedure itself, meaning a routine pre-procedure history and physical examination is not separately billable. Modifier 25 is only appropriate if the E/M service extends beyond the scope of this bundled work, such as evaluating an unrelated problem or providing a complex E/M service related to the procedure. For procedures with a 90-day global period, the E/M service that resulted in the decision for surgery is reported with Modifier 57, not Modifier 25.
Common Misapplications and Error Prevention
Misuse of Modifier 25 often stems from a misunderstanding of what constitutes “significant” and “separately identifiable.” A common error is appending the modifier for routine pre-operative work, such as a brief history and physical integral to the procedure’s safe performance. Using the modifier simply because a patient was seen before a procedure, without the E/M meeting the threshold of separate medical necessity, is inappropriate. The Office of the Inspector General (OIG) has identified the misuse of this modifier as a source of improper payments, subjecting its use to scrutiny by payers.
To prevent errors, providers should confirm the E/M service was medically necessary and distinct from the procedure itself, not just a necessary step toward performing the procedure. Utilizing a different diagnosis code for the E/M service than the procedure, when clinically appropriate, visually supports the separate nature of the two services. Meticulous documentation that clearly segregates the E/M service from the procedure is the most effective strategy for error prevention.