Modifier 25: The 2026 Guide to Billing a Significant, Separately Identifiable E/M Service

Last Updated: January 2026 | Verified for 2026 AMA, CPT & CMS Guidelines

Quick Reference: Modifier 25

• Definition: Significant, Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.
• Purpose: Allows a provider to bill a separate E/M service on the same day a procedure or other service is performed, when the E/M is distinct and not a routine pre-service evaluation.
• Appended To: The E/M code only — never to the procedure code.
• Key Requirement: The E/M must be significant and separately identifiable — it must stand on its own clinical merit, independent of the procedure performed.
• 2025 Update (G2211): Beginning January 1, 2025, HCPCS code G2211 may be billed alongside an E/M code reported with Modifier 25, but only when a Part B preventive service, AWV, or vaccine administration is also present on the same date of service .
• Documentation: Separate documentation for the E/M and the procedure is required by most payers. Vague or templated notes are the #1 reason for audit denial and recoupment.
• Compliance Risk: Modifier 25 is one of the most audited and most denied modifiers in all of medical billing. Inadequate documentation is the leading cause of improper payment findings by CMS and the OIG. Modifier 25 is one of the most powerful — and most misused — tools in a medical biller’s or physician’s arsenal. When appended correctly to an E/M service code, it signals to the payer that on the same date of service, the provider performed a distinct, medically necessary evaluation and management encounter that is separate from any procedure or other service also billed that day. Without this modifier, payers automatically bundle (deny) the E/M into the procedure, assuming the evaluation was merely a pre-service check before performing the procedure. Used incorrectly, Modifier 25 is a significant source of billing compliance risk, False Claims Act exposure, and post-payment audit recoupment. Understanding exactly when — and how — to use it is critical for every specialty that performs procedures in an office, clinic, or facility setting.

1. Definition & Official CPT Description

The official AMA CPT definition of Modifier 25 is:

“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.”

Breaking this down word by word is essential to understanding its correct application:

• “Significant”: The E/M service must rise above a trivial pre-procedure check (e.g., confirming the patient’s identity and site). It must reflect genuine medical decision-making or a substantial clinical history and examination.
• “Separately Identifiable”: The E/M must be a distinct service. The documentation must make it clear that the E/M visit and the procedure address different clinical questions, conditions, or decision points — or that the evaluation went substantially beyond what is normally required to perform the procedure.
• “Same Physician or Other Qualified Health Care Professional”: The modifier applies only when the same provider bills both the E/M and the procedure. Physicians of the same specialty within the same group practice are considered the same physician and must bill as though they were a single physician .
• “Same Day”: Both the E/M and the procedure must occur on the same calendar date of service. The modifier is appended to the E/M code (e.g., 99213-25, 99214-25), never to the procedure code. This is a common entry-level billing error that causes claim rejections. Note also that Modifier 25 should not be appended to CPT code 99211, as this code does not involve physician decision-making .

2. When to Use Modifier 25: The Core Rule

The decision to append Modifier 25 should always begin with a single clinical question: “Did the physician perform a medically necessary E/M service today that is distinct from the decision to perform — or the performance of — the procedure?” If the answer is yes, and the documentation supports it, Modifier 25 is appropriate. If the evaluation was merely a routine pre-procedure check with no independent clinical significance, Modifier 25 is not appropriate. The AMA has emphasized that answering “yes” to the following questions indicates whether Modifier 25 is justified: (1) Did the physician perform and document the level of MDM or total time necessary to support the E/M code billed? (2) Is the E/M service above and beyond the usual pre- and post-operative care associated with the procedure? (3) Is the service significant and separately identifiable in the medical record?

Appropriate Use Scenarios

• New Problem Identified: A patient presents for a scheduled injection (e.g., knee corticosteroid injection, CPT 20610). During the visit, the physician evaluates a new complaint of chest tightness. The E/M for the chest tightness is separate from the injection. Correct: Bill 99213-25 + 20610.
• Unrelated Condition Evaluated: A patient is seen for destruction of a skin lesion (CPT 17110). The physician also evaluates a rash on the patient’s arm that is completely unrelated to the lesion being destroyed. Correct: Bill 99213-25 + 17110.
• Substantially Expanded Evaluation: A patient comes in for a planned laceration repair. Before suturing, the physician performs an extensive examination to rule out nerve damage and tendon involvement, reviews the patient’s anticoagulation status, and counsels about tetanus. The E/M substantially exceeds what is typically pre-service for a repair. Correct: Bill E/M-25 + repair code.
• Initial Visit + Procedure: A new patient presents with a complaint. After a complete history and examination, the physician decides to perform a procedure that same day (e.g., excision of a cyst discovered during the visit). The full E/M is separate and drove the decision to treat. Correct: Bill E/M-25 + procedure.

Inappropriate Use Scenarios

• Routine Pre-Procedure Check: A patient presents specifically for a pre-scheduled vaccination. The physician briefly reviews the chart and confirms there are no contraindications. The E/M is bundled into the vaccine administration. Incorrect to bill E/M-25 here.
• E/M for the Same Condition as the Procedure: A patient presents with knee pain. The physician examines the knee and decides to inject it. The examination of the knee is considered pre-service work for the injection — it is not separate. Incorrect to bill E/M-25 unless there are truly distinct clinical issues evaluated.
• Minor Procedures with Included Pre-Service: Many minor procedures (e.g., wart destruction, simple I&D) include a “pre-service evaluation” in their RVU valuation. A brief check of the area does not constitute a separately identifiable E/M. Incorrect to bill E/M-25 in this scenario. The “Same Condition” Trap: The most common inappropriate use of Modifier 25 is when providers bill an E/M and a procedure for the same diagnosis and same condition with no distinct clinical work. For example: billing 99213-25 for “knee pain” alongside a knee injection (20610) for “knee pain,” with no additional evaluation documented beyond what is needed to perform the injection, is a red flag that payers and auditors will target. Note that a different ICD-10 code is not required for Modifier 25 — but when the same diagnosis is used for both the E/M and procedure, the documentation must be especially robust in articulating separate clinical work .

3. Audit-Proof Documentation Standards

Documentation is the make-or-break factor for Modifier 25. Many practices correctly identify clinical situations that warrant the modifier but then fail to document them in a way that survives an audit. CMS explicitly states that the documentation of the E/M service and the procedure “must be clearly separate and distinct in the medical record.” If both services are mixed in a single visit entry without any separation, the requirement for a “separately identifiable” service is not met .

The Two-Note Strategy

The most defensible approach is to maintain two separate, clearly delineated documentation sections within the encounter note:

• Section 1 — The E/M Note: Documents the history, examination, and medical decision-making (or time) for the separate, identifiable evaluation. Must clearly articulate the clinical problem being addressed, what was found, and what clinical decisions were made.
• Section 2 — The Procedure Note: Documents the indication, technique, patient consent, and post-procedure status for the procedure performed.

What the E/M Note Must Contain

• Chief Complaint: A clear statement of the problem being evaluated in the E/M — distinct from the procedure indication (e.g., “Patient presents with new onset fatigue and dyspnea, separate from scheduled wound check”).
• Medical Decision-Making (MDM) or Time: Under 2023–2026 AMA E/M guidelines, code selection is based on MDM or total time. The note must support the level of E/M billed on its own merits.
• Assessment & Plan: A distinct plan for the separately evaluated problem — separate orders, referrals, prescriptions, or follow-up instructions — demonstrates the “significant” nature of the E/M.
• Diagnosis Linkage: While different ICD-10 codes are not strictly required, using the same diagnosis for both the E/M and the procedure without additional narrative explanation is a leading audit trigger.

Documentation Language Examples

• Weak (Audit Risk): “Patient here for knee injection. Knee pain assessed. Injection performed.”
• Strong (Audit-Proof): “Patient presents today for scheduled right knee corticosteroid injection (20610) for osteoarthritis (M17.11). Additionally, patient reports new onset bilateral ankle swelling and exertional dyspnea for 3 days, not present at last visit. On examination: 2+ pitting edema bilateral ankles, JVD noted, lung bases with fine crackles. Assessment: New onset decompensated heart failure (I50.9). Plan: Furosemide 40mg PO daily initiated, BMP and BNP ordered, cardiology referral placed. This evaluation is conducted separately from and independent of the injection service.”

4. The Bundling Problem: Why Modifier 25 Exists

Without Modifier 25, payers apply the National Correct Coding Initiative (NCCI) bundling edits — a set of CMS-developed rules that automatically deny or bundle E/M codes billed on the same day as certain procedures. The NCCI logic assumes that the E/M is a pre-service component of the procedure and therefore not separately reimbursable. Modifier 25 functions as an NCCI “modifier indicator 1” override. When a procedure has a modifier indicator of “1” (most E/M + minor procedure combinations), the payer accepts that Modifier 25 on the E/M can bypass the bundle — but only with appropriate documentation.

NCCI Modifier Indicator “0” Procedures: Some procedure codes carry an NCCI modifier indicator of “0,” meaning the bundle cannot be overridden — even with Modifier 25. For these pairs, the E/M is always considered bundled into the procedure and cannot be billed separately on the same day. Applying Modifier 25 to a “0” pair will result in denial or may constitute improper billing. Always verify the NCCI modifier indicator before appending Modifier 25.

5. Medicare & CMS-Specific Rules (Including 2025 G2211 Update)

Core CMS Policy

CMS recognizes Modifier 25 as a valid override for NCCI bundling edits where modifier indicator “1” applies. CMS has emphasized in its September 2025 MLN Booklet (MLN006764) and in provider education materials that the E/M must be medically necessary, significant, and separately documented — not simply a pre-procedure screening .

2025 Update: G2211 and Modifier 25 (Effective January 1, 2025)

Important 2025 Policy Change: Beginning January 1, 2025, CMS allows HCPCS code G2211 (the Office/Outpatient E/M visit complexity add-on code) to be billed alongside an E/M code reported with Modifier 25, but only when the same practitioner also bills a Part B preventive service, Annual Wellness Visit (AWV), or vaccine administration on the same date of service. Outside of these specific scenarios, G2211 may not be reported when Modifier 25 is appended to the associated O/O E/M visit code (CPT codes 99202–99205 or 99211–99215) .

Preventive Visit + Problem-Oriented E/M (Same Day)

A patient presenting for an Annual Wellness Visit (AWV) or Initial Preventive Physical Examination (IPPE) who also has a new or acutely worsening problem evaluated on the same day is one of the most common — and most audited — Modifier 25 scenarios:

• If the physician addresses a new or acute problem beyond the scope of the preventive visit, a separate E/M may be billed with Modifier 25.
• The problem-oriented E/M must be medically necessary and separately documented.
• Medicare has a cost-sharing distinction: the preventive visit is typically covered at 100% (no cost-sharing), while the problem-oriented E/M is subject to Part B deductible and coinsurance. Providers must inform patients of this potential additional cost.
• As of January 1, 2025, G2211 may also be billed in this scenario when applicable conditions are met (see above).

Vaccine Administration + E/M (Same Day)

Administering a vaccine (e.g., influenza, pneumococcal) covered under Part B on the same day as an E/M does not automatically justify a separate E/M. However, if the patient presents with a distinct medically necessary problem, a separate E/M with Modifier 25 is appropriate. As noted above, G2211 may also be payable in this scenario beginning January 1, 2025 .

Intravitreal Injections: A High-Risk Area in 2025–2026

The OIG published a significant audit report in December 2025 finding that for 42% of intravitreal injections during the audit period, providers billed for E/M services on the same day using Modifier 25. The OIG identified $124 million in potentially improper E/M payments and recommended that CMS update requirements and conduct medical reviews. The OIG emphasized that the decision to perform an intravitreal injection is considered part of the minor surgical procedure itself and should not be separately billed — only a truly distinct clinical evaluation qualifies for Modifier 25 in this context . Ophthalmology practices should review their Modifier 25 utilization immediately in light of this report.

Medicare Audit Frequency

CMS Recovery Audit Contractors (RACs) and OIG auditors have consistently identified Modifier 25 billing as a high-risk area across multiple specialties — particularly dermatology, ophthalmology, orthopedics, and podiatry. A substantial portion of audited claims do not meet documentation requirements, resulting in large-scale recoupments .

6. Commercial Payer Variations

Unlike many CPT rules that are uniformly applied, commercial payers vary significantly in their Modifier 25 policies. This is a critical area of practice-specific research for billing teams.

• UnitedHealthcare: Follows NCCI editing broadly and requires that the E/M represent a “significant, separately identifiable” service. UHC has published specific policies stating that a different diagnosis is preferred (though not always required) to support a -25 modifier claim.
• Aetna: Aligns with CMS policy but applies heightened scrutiny to dermatology and ophthalmology claims billed with -25.
• Cigna: Has implemented pre-payment review programs for high-frequency Modifier 25 billers and requires robust documentation. The AMA has specifically challenged Cigna’s overly restrictive Modifier 25 policies, which the AMA argues create administrative burdens that deter prompt patient care .
• Medicaid (State-Specific): Medicaid programs vary dramatically by state. Some state Medicaid plans do not recognize Modifier 25 for certain procedure categories. Billing teams must verify state-specific policies annually. Payer Policy Verification: Always obtain and review the specific Modifier 25 policy from each payer’s provider manual annually. Commercial payer policies can and do change from year to year and may differ substantially from CMS guidelines. Billing on assumptions without verifying payer-specific policy is a leading cause of systematic underpayment or audit exposure.

7. Most Common Billing Errors & Audit Red Flags

Red Flags That Trigger Audits

• High Modifier 25 Utilization Rate: If a practice bills Modifier 25 on a disproportionately high share of procedure claims relative to specialty peers, it will appear as a statistical outlier and attract payer or RAC attention.
• Same ICD-10 Code for E/M and Procedure With No Additional Narrative: Billing the same diagnosis for both without distinct documentation signals that the work was not truly separate.
• Template-Driven or Copy-Forward E/M Notes: Auto-populated or boilerplate notes lacking patient-specific detail do not support the “significant” standard. Auditors specifically look for individualized, clinically relevant documentation.
• Every Patient Gets an E/M: If a provider appends -25 to virtually every procedure performed, auditors view this as a systemic billing pattern rather than clinically driven decision-making.
• Intravitreal Injection + E/M Claims: Following the December 2025 OIG report, expect heightened scrutiny of ophthalmology claims pairing intravitreal injections with same-day E/M visits billed under Modifier 25 .

Most Common Billing Errors

• Appending -25 to the Procedure Code: Modifier 25 goes on the E/M code only. Appending it to the procedure code will result in claim rejection or processing errors.
• Using Modifier 25 Instead of Modifier 57: For major surgeries (90-day global period), the decision to perform surgery requires Modifier 57, not Modifier 25. Using the wrong modifier results in denial or improper payment (see Section 9).
• Ignoring NCCI Modifier Indicator “0” Pairs: Appending Modifier 25 to a code pair with a “0” modifier indicator will not bypass the bundle and may constitute a compliance violation.
• Incorrectly Reporting G2211 With Modifier 25: As of January 2025, G2211 is only payable with a Modifier 25 E/M when a Part B preventive service, AWV, or vaccine administration is also present. Billing G2211 + Modifier 25 outside this scenario will result in denial .
• Billing an E/M Level Higher Than Documented: The E/M code must be supported by the documentation on its own merits. Upcoding the E/M level to increase reimbursement when Modifier 25 is used is a False Claims Act risk.

8. Specialty-Specific Examples & Scenarios

Scenario 1: Dermatology — Lesion Destruction + Unrelated Problem

Patient: Established patient presents for scheduled destruction of 5 seborrheic keratoses (17111). During the visit, patient mentions a new mole on their back they are worried about. Physician performs a full skin exam focused on the new lesion, dermoscopy, biopsy decision-making, and counsels regarding sun protection and skin cancer surveillance. Coding: 99213-25 + 17111 + 11102 (if biopsy performed). Rationale: The evaluation of the new suspicious lesion — including history, examination, and decision-making regarding biopsy — is a separately identifiable E/M distinct from the pre-scheduled keratosis destruction.

Scenario 2: Orthopedics — Joint Injection + New Complaint

Patient: Established patient with known right knee osteoarthritis presents for a scheduled right knee corticosteroid injection (20610). Patient also reports new left shoulder pain for 2 weeks, never previously evaluated. Physician takes a focused history, performs a shoulder examination, orders X-rays, and initiates a treatment plan. Coding: 99213-25 + 20610. Rationale: The left shoulder evaluation is entirely distinct from the right knee injection — different anatomical site, different diagnosis, independent clinical work. The E/M note documents the shoulder evaluation separately from the injection procedure note.

Scenario 3: Primary Care — Preventive Visit + Acute Problem

Patient: Medicare patient presents for Annual Wellness Visit (G0439). During the visit, patient reports 3 days of dysuria, frequency, and suprapubic discomfort. Physician performs a problem-focused evaluation of the UTI complaint, orders urinalysis, and prescribes Nitrofurantoin. Coding: 99213-25 + G0439. If ongoing care relationship applies, consider also billing G2211 (effective January 1, 2025, G2211 is payable in this scenario per CMS policy). Rationale: The acute UTI evaluation is outside the scope of the wellness visit and required separate medical decision-making and a prescription. Note: Advise Medicare patient of potential cost-sharing on the problem-oriented E/M.

Scenario 4: Ophthalmology — Intravitreal Injection + E/M (High Audit Risk in 2026)

Patient: Patient with wet AMD presents for scheduled intravitreal injection (67028). Physician performs a comprehensive ophthalmological examination to evaluate visual acuity, new OCT findings suggesting unexpected disease progression in the fellow eye, and makes a clinical decision to modify the treatment interval. Coding: 92014-25 + 67028 — only if the documentation clearly supports that the comprehensive exam was performed for a distinct clinical reason beyond confirming the injection is needed. Caution: Following the December 2025 OIG report identifying up to $124 million in potentially improper payments for this exact scenario, ophthalmology practices must ensure robust documentation. The OIG has stated that the decision to perform an intravitreal injection is part of the minor surgical procedure and should not be separately billed unless a truly distinct clinical evaluation is performed and documented .

Scenario 5: Incorrect Use — Same Problem, Same Day

Patient: Established patient presents with right knee pain. Physician evaluates the knee and decides to perform a corticosteroid injection. Physician bills 99213-25 + 20610 with diagnosis M17.11 on both. Coding: Inappropriate use of Modifier 25. Rationale: The E/M is the pre-procedure evaluation for the injection — this work is included in the procedure’s RVU value. Unless the physician evaluated a separate, distinct problem, the E/M is bundled and Modifier 25 is not appropriate.

9. Modifier 25 vs. Modifier 57: Key Differences

These two modifiers are frequently confused and incorrectly interchanged. The distinction is based entirely on the global period of the procedure being performed.

10. Global Surgery Package Interaction

CMS defines the global surgery package as a bundled payment that includes pre-operative evaluation on the day of surgery (and 1 day before for major procedures), intraoperative services, and routine post-operative care for the duration of the global period (0, 10, or 90 days) . The rules governing Modifier 25 in this context are as follows:

• Day of Minor Surgery (0 or 10-day global): The pre-procedure evaluation for the same condition is bundled. A separate E/M for a different, distinct condition may be billed with Modifier 25.
• Day of Major Surgery (90-day global): The E/M during which the decision to perform surgery is made may be billed with Modifier 57. All other pre-op evaluations for the surgical condition on the day of and day before surgery are bundled.
• During Post-Op Global Period: E/M visits for complications or conditions unrelated to the surgery may be billed with Modifier 24 (not Modifier 25) during the global period.

11. Compliance Best Practices

Given that Modifier 25 is consistently among the top billing compliance risk areas identified by the OIG and CMS — including a major December 2025 OIG audit — a formal practice-level compliance program is strongly recommended.

Practice-Level Controls

• Annual Modifier 25 Audits: Conduct a retrospective review of a random sample of Modifier 25 claims (at least 20–30 charts per provider, per year). Identify patterns of misuse before payers do.
• Provider Education: Train all providers — especially those who perform procedures — on the documentation standards for Modifier 25. Focus on the “two-note” approach and the importance of a distinct E/M assessment and plan, including the 2025 G2211 policy update.
• Utilization Benchmarking: Compare each provider’s Modifier 25 utilization rate to specialty-specific benchmarks. Significant outliers warrant focused review.
• EHR Smart Templates: Build EHR templates that prompt providers to separately document the E/M and procedure, link appropriate diagnosis codes, and include a rationale for the separate service when applicable.
• Coder-Provider Communication: Billing staff should be empowered to query providers when a Modifier 25 claim appears unsupported by documentation, before submission — not after a denial or audit.

Responding to a Modifier 25 Audit

• Request the payer’s specific written criteria for Modifier 25 compliance.
• Provide complete medical records — both the E/M documentation and the procedure documentation — for each audited claim.
• Prepare a written narrative explaining the clinical circumstances that justified the separate E/M for disputed claims.
• If recoupment is demanded, calculate whether an appeal is warranted based on documentation strength and dollar amount at issue.
• Use audit findings to drive provider education and documentation improvement, not just as a compliance event.