Scroll Top


modifier 25
modifier 25

-25 Modifier

​Many times, a patient’s “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit into something more.

According to CPT, separate, significant physician evaluation and management (E/M) work that goes above the physician work normally associated with a preventive medicine service or a minor surgical procedure is additionally billable. The code that tells the insurer you should be paid for both services is modifier -25. Used correctly, it can generate extra revenue.

Modifier -25 indicates that on the day of a procedure, the patient’s condition required a significant, separately identifiable E/M service.

***Unfortunately, not all insurers will pay you for the separate E/M service even if you code in compliance with CPT rules. Be sure to have your staff appeal any denied or bundled claims. A review of your documentation by the insurer may result in payment for your work.

The use of modifier 25 has specific requirements.

  1. The E/M service must be significant. The problem must warrant physician work that is medically necessary. This can be defined as a problem that requires treatment with a prescription or a problem that would require the patient or family to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M-25 service.
  2. The E/M service must be separate. The problem must be distinct from the other E/M service provided (eg, preventive medicine) or the procedure being completed. Separate documentation for the E/M-25 problem is helpful in supporting the use of modifier 25 and especially important to support any necessary denial appeal.
  3. The E/M service must be provided on the same day as the other procedure or E/M service. This may be at the same encounter or a separate encounter on the same day.
  4. Modifier 25 should always be attached to the E/M code. If provided with a preventive medicine visit, it should be attached to the established office E/M code (99211–99215).
  5. The separately billed E/M service must meet documentation requirements for the code level selected. It will sometimes be based on time spent counseling and coordinating care for chronic problems.


For more on Medical Billing & Coding, Healthcare Administration, and Insurance News and Updates, you’re already at the right place. Be sure to stay on top of everything by subscribing to the Rx for Success Medical Billing Blog here!

Resources & Credits:
“Any trademarks, logos, or links (sources) used throughout this blog are the property of their respective owners.”

Privacy & Cookie Information
When you visit our website, it may store information through your browser from specific services, usually in form of cookies. You will find our privacy and cookie policy below. By clicking "I Agree", you confirm you consent to our policies and/or have read them fully.

You can change your cookie setting's anytime. Please refer to your browser's help page to confirm how to disable cookies. Please note that blocking some types of cookies may impact your experience on our website and the services we offer.
%d bloggers like this: