Modifier 25: A Significant, Separate E/M Visit on the Same Day as a Procedure
Modifier 25 tells the payer an E/M visit on the same day as a minor procedure was significant and separately identifiable, so both get paid instead of the visit bundling into the procedure. It goes on the E/M code only, and it is the single most audited modifier in outpatient billing.
- Applies to
- E/M codes only (99202-99215 etc.), same day as a minor procedure
- Payment impact
- Unlocks full payment for the E/M in addition to the procedure
- Audit risk
- High — a perennial OIG and payer prepay-review target
- Common denial
- CO-97 (bundled) when missing; refund demands when overused
What does modifier 25 do?
It certifies that an E/M service performed on the same day as a minor procedure (0- or 10-day global period) was significant and separately identifiable from the procedure's built-in evaluation work. Without it, payers bundle the visit into the procedure and deny it CO-97.
This is the reference card. For decision trees, audit-proof documentation language, and payer-by-payer quirks, read the full Modifier 25 guide.
When do you use it?
When the provider addressed a problem above and beyond the procedure itself. Classic example: a Medicare patient comes in for a scheduled joint injection (20610) but also reports new chest tightness the provider works up. Bill 99214-25 + 20610 — both pay. If the visit was only "knee hurts, here is your injection," bill 20610 alone.
When is it wrong or a denial trigger?
- Appending it to every procedure-day visit by habit — the exact pattern payer analytics flag.
- Using it with major surgery (90-day global). That is modifier 57 territory.
- Using it for the visit where the only work was deciding to do today's minor procedure.
What changed for 2026?
The G2211 interaction matters most: since 2025, Medicare pays G2211 with a modifier-25 E/M only when billed the same day as an annual wellness visit or Part B preventive service, and starting January 1, 2026, G2211 also extends to home-visit E/M codes 99341-99350. Document the separate work in its own paragraph so the two services are visibly distinct.
Frequently asked questions
Always on the E/M code, never on the procedure. If your claim shows 11102-25, it is wrong. The correct pattern is 99213-25 on one line and the procedure code unmodified on the next.
No. CPT explicitly says the E/M and procedure may share a diagnosis. What matters is that the visit work went significantly beyond the routine pre- and post-work of the procedure and the note proves it on its own.
Only in the carved-out scenario: since January 1, 2025, Medicare pays G2211 alongside a modifier-25 E/M when the same practitioner performs an annual wellness visit (G0438/G0439) or another Part B preventive service the same day. Outside that, G2211 with modifier 25 still denies.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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