Modifier 25 is used to describe a
"significant and separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service."
Note: Effective Oct. 1, 2026, Priority Health will begin following rules from the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) related to new versus established patients. For the reporting and billing of professional face to face services, physicians and qualified health professionals (QHPs) who share the same specialty and subspecialty within the same group practice will be considered a single provider.
- Modifier 25 should be appended only to E/M service codes within the range of 92002-92014, 99201-99499, and with HCPCS codes G0101 and G0175.
- Minor procedures already include E/M elements; only use modifier 25 when services are performed over and above what is typical for the procedure.
- The physician will need to indicate that the patient's condition required a service above and beyond what is expected for other services provided on the same day.
- Documentation within the medical record must support the level of E/M service reported.
- Notes are also required when you resubmit a code with modifier 25.
Incorrect uses of modifier 25
No other services on the same day: E/M services reported with modifier 25 and no other claim lines or services performed by the same provider on the same date of service will deny.
Example: Provider A performs a level IV E/M service, 99214, and provider B performs a vaccine administration, 90471. Provider A has not performed a significant, separately identifiable service, so would not append modifier 25 to 99214.
Decision to perform major surgery: Do not use modifier 25 to report an E/M service that resulted in a decision to perform a major surgery (use modifier 57 instead). A major surgery is defined as having a 90-day global period.
Exception: Critical care services with the decision to perform minor/major surgery, Priority Health follows CMS guidance using modifier 25 to report critical care services (CPT code 99291 and 99292) that result in a decision to perform a minor/major surgery.
CMS criteria for the use of modifier 25
Per CMS National Correct Coding Initiative, Chapter 11:
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E/M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E/M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.